Medical field

2021

BASIC MEDICAL REVIEW

FIELD OF MEDICAL

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Audiology Electropathy Microbiology Nutrition and dietics Optometry Pharmacognosy Physiotherapy Speech therapy Ayurveda Homeopathy Naturopathy Ophthalmologist Occupational therapy Pharmacovigilance Psychiatry Veterinary science Dentistry Medical lab technologist Nursing Orthopedics Pathology Pharmacy Radiography

AudiologyAudiology is a branch of science that studies hearing, balance, and related disorders. Audiologists treat those with hearing loss and proactively prevent related damage. By employing various testing strategies, audiologists aim to determine whether someone has normal sensitivity to sounds. If hearing loss is identified, audiologists determine which portions of hearing are affected, to what degree, and where the lesion causing the hearing loss is found. If an audiologist determines that a hearing loss or vestibular abnormality is present he or she will provide recommendations for interventions or rehabilitation .

In addition to diagnosing audio logic and vestibular pathologies, audiologists can also specialize in rehabilitation of tinnitus, hyperacusis, misophonia, auditory processing disorders, cochlear implant use and/or hearing aid use.

Audiologists can provide hearing health care from birth to end-of-life.

Audiologist An audiologist is a health-care professional specializing in identifying, diagnosing, treating, and monitoring disorders of the auditory and vestibular systems. Audiologists are trained to diagnose, manage and/or treat hearing, tinnitus, or balance problems. They dispense, manage, and rehabilitate hearing aids and assess candidacy for and map cochlear implants. They counsel families through a new diagnosis of hearing loss in infants, and help teach coping and compensation skills to late-deafened adults. They also help design and implement personal and industrial hearing safety programs, newborn hearing screening programs, school hearing screening programs, and provide special or custom fitted ear plugs and other hearing protection devices to help prevent hearing loss. Audiologists are trained to evaluate peripheral vestibular disorders originating from pathologies of the vestibular portion of the inner ear. They also provide treatment for certain vestibular and balance disorders such as Benign Paroxysmal Positional Vertigo. In addition, many audiologists work as auditory or acoustic scientists in a research capacity.

Audiologists are trained in anatomy and physiology, hearing aids, cochlear implants, electrophysiology, acoustics, psychophysics and psychoacoustics, neurology, vestibular function and assessment, balance disorders, counseling and communication options such as sign language. Audiologists may also run a neonatal hearing screening program which has been made compulsory in many hospitals in US, UK and India.

An audiologist usually graduates with one of the following qualifications: BSc, MSc, Au.D., STI, PhD, or ScD, depending the program and country attended.

History The use of the terms audiology and audiologist in publications has been traced back only as far as 1946. The creator of the term remains unknown, but Berger identified possible originators as Mayer BA Schier, Willard B Hargrave, Stanley Nowak, Norman Canfield, or Raymond Carhart. In a biographical profile by Robert Galambos, Hallowell Davis is credited with coining the term in the 1940s, saying the then-prevalent term "auricular training" sounded like a method of teaching people how to wiggle their ears. the first US university course for audiologists was offered by Carhart at Northwestern University, in 1946.

Audiology was born of interdisciplinary collaboration. The substantial prevalence of hearing loss observed in the veteran population after World War II inspired the creation of the field as it is known today. The International Society of Audiology was founded in 1952 to "…facilitate the knowledge, protection and rehabilitation of human hearing" and to "…serve as an advocate for the profession and for the hearing impaired throughout the world." It promotes interactions among national societies, associations and organizations that have similar missions, through the organization of a biannual world congresses, through the publication of the scientific peer-reviewed International Journal of Audiology

and by offering support to the World Health Organization's efforts towards addressing the needs of the hearing impaired and deaf community.

Requirements Australia In Australia Audiologists must hold a Master of Audiology, Master of Clinical Audiology, Master of Audiology Studies or alternatively a bachelor's degree from overseas certified by the VETASSESS. Although audiologists in Australia are not required to be a member of any professional body, audiology graduates can undergo a clinical training program or internship leading to accreditation with Audiology Australia or the Australian College of Audiology which involves supervised practice and professional development, and typically lasts one year.

To provide rehabilitative services to eligible pensioners, war veterans, and children and young adults under the age of 26 as part of the Hearing Services Program, an audiologist must hold a qualified practitioner number which can be sought by first obtaining accreditation.

Brazil In Brazil, audiology training is part of speech pathology and audiology undergraduate, four-year courses. The University of São Paulo was the first university to offer a bachelor's degree, and it started operations in 1977. At the federal level, the recognition of the educational programs and the profession of speech pathologist and audiologist took place on December 9, 1981, signed by President João Figueiredo . The terms audiology and audiologist can be tracked in Brazilian publications since 1946. The work of audiologists in Brazil was described in 2007.

Canada In Canada, a masters of science is the minimum requirement to practice audiology in the country. The profession is regulated in New Brunswick, Quebec, Ontario, Manitoba, Saskatchewan, Alberta, and British Columbia, where it is illegal to practice without being registered as a full member in the appropriate provincial regulatory body.

Bangladesh A BSc in audiology and speech language pathology is required.

India To practice audiology, professionals need to have either a bachelor's or a master's degree in audiology and be registered with Rehabilitation Council of India.

Malaysia Three Malaysian educational institutions offer degrees in audiology.

United Kingdom There are currently five routes to becoming a registered audiologist: Fads’ in hearing aid audiology BSc in audiology MSc in audiology

Fast-track conversion Diploma for those with a BSc in another relevant science subject, available at Southampton, Manchester, UCL, London, and Edinburgh BSc in clinical physiology available at Glasgow Caledonian University United States In the United States, audiologists are regulated by state licensure or registration in all 50 states and the District of Columbia. Starting in 2007, the doctor of audiology became the entry-level degree for clinical practice for some states, with most states expected to follow this requirement very soon, as there are no longer any professional programs in audiology which offer the master's degree. Minimum requirements for the Au.D. degree include a minimum of 75 semester hours of post-baccalaureate study, meeting prescribed competencies, passing a national exam offered by Praxis Series of the Educational Testing Service, and practicum experience that is equivalent to a minimum of 12 months of full-time, supervised experience. Most states have continuing education renewal requirements that must be met to stay licensed. Audiologists can also earn a certificate from the American Speech-Language-Hearing Association or seek board certification through the American Board of Audiology. Currently, there are over 70 Au.D. programs in the United States.

In the past, audiologists have typically held a master's degree and the appropriate healthcare license. However, in the 1990s the profession began to transition to a doctoral level as a minimum requirement. In the United States, starting in 2007, audiologists were required to receive a doctoral degree in audiology from an accredited university graduate or professional program before practicing. All states require licensing, and audiologists may also carry national board certification from the American Board of Audiology or a certificate of clinical competence in audiology from the American Speech-Language-Hearing Association.

Pakistan In Pakistan, a master’s or doctoral degree in audiology is required to practice this profession. This medical degree must come from a recognised institute, most of which are government, otherwise the person didn’t get the license to practice the audiology. Pakistan Medical and Dental Council issues the practicing license to all the medical students. Besides these, the person who provides the medical instruments to these doctors should also have the certificate of accreditation, issued by the Pakistan National Accreditation Council .

Portugal The exercise of audiologist profession in Portugal necessarily imply the qualifications degree in audiology or legally equivalent as defined in Decree-Law 320/99 of August 11 Article 4.

South Africa In South Africa, there are currently five institutions offering training in audiology. The institutions offer different qualifications that make one eligible for practicing audiology in South Africa. The qualifications are as follows, I) B. Audiology, II) BSc. Audiology, III) B. Communication Pathology, and IV) B. Speech Language Pathology and Audiology . All practicing audiologists are required to be registered with the Health Professional Council of South Africa .

See also Audiology and hearing health professionals in developed and developing countries Auditory brainstem response

Auditory agnosia Auditory processing disorder Auditory verbal agnosia Audiometric Audiometry Balance disorder Bone anchored hearing aid Cochlear implant Dichotic listening test Earplug Electronystagmography European Federation of Audiology Societies Hearing Aid Hearing impairment Listening Noise induced hearing loss Otoacoustic emissions Otolaryngology Otology Speech and language pathology Spatial hearing loss Tympanometry.

ElectropathyElectro homoeopathy is a derivative of homeopathy invented in the 19th century by Count Cesar Mattie. The name is derived from a combination of electro and homeopathy. Electro homeopathy has been defined as the combination of electrical devices and homeopathy.

History and criticism Electrohomeopathy was devised by Cesar Mattie in the latter part of the 19th century. Mattei, a nobleman living in a castle in the vicinity of Bologna, studied natural science, anatomy, physiology, pathology, chemistry and botany. He ultimately focused on the supposed therapeutic power of "electricity" in botanical extracts. Mattei made bold, unsupported claims for the efficacy of his treatments, including the claim that his treatments offered a nonsurgical alternative to cancer. His treatment regimens were met with scepticism by mainstream medicine: The electrohomeopathic system is an invention of Count Mattei who prates of "red", "yellow" and "blue", "green" and "white" electricity, a theory that, in spite of its utter idiocy, has attracted a considerable following and earned a large fortune for its chief promoter.

Notwithstanding criticisms, including a challenge by the British medical establishment to the claimed success of his cancer treatments, electro homeopathy had adherents in Germany, France, the US and the UK by the beginning of the 20th century; electro homeopathy had been the subject of approximately 100 publications and there were three journals dedicated to it.

Philosophy Remedies are derived from what are said to be the active micro nutrients or mineral salts of certain plants. One contemporary account of the process of producing electrohomeopathic remedies was as follows: As to the nature of his remedies we learn ... that ... they are manufactured from certain herbs, and that the directions for the preparation of the necessary dilutions are given in the ordinary jargon of homeopathy. The globules and liquids, however, are "instinct with a potent, vital, electrical force, which enables them to work wonders". This process of "fixing the electrical principle" is carried on in the secret central chamber of a Neo-Moorish castle which Count Mattie has built for himself in the Bolognese Apennines ... The "red electricity" and "white electricity" supposed to be "fixed" in these "vegetable compounds" are in their very nomenclature and suggestion poor and miserable fictions.

According to Mattie’s own ideas however, every disease originates in the change of blood or of the lymphatic system or both, and remedies can therefore be mainly divided into two broad categories to be used in response to the dominant affected system. Mattie wrote that having obtained plant extracts, he was "able to determine in the liquid vegetable electricity". Allied to his theories and therapies were elements of Chinese medicine, of medical humours, of apparent Brownianism, as well as modified versions of Samuel Hahnemann's homeopathic principles. Electrohomeopathy has some associations with Spagyric medicine, a holistic medical philosophy claimed to be the practical application of alchemy in medical treatment, so that the principle of modern electrohomeopathy is that disease is typically multiorganic in cause or effect and therefore requires holistic treatment that is at once both complex and natural.

Modern usage A symposium took place in Bologna in 2008 to mark the 200th anniversary of the birth of Cesare Mattei, with attendees from India, Pakistan, Germany, UK, and the USA. Electrohomeopathy is practiced predominantly in India and Pakistan, but there are also a number of electrohomeopathy organizations and institutions worldwide.

See also

List of ineffective cancer treatments References Further reading Mattei, Count Cesare The Principles of Electro homoeopathy: a new science, 1880 Gladden, Aurelius J L Stepping Stones to Electro-Homoeopathy, 1892 Krauss, Theodor Die grundgelete der-Elektra homeopathies, 1921 Kudus, Debasish, Jayasuriya, Anton, Ahmed, Mahinuddin Materia Medical for the New Age Man, 2015.

MicrobiologyMicrobiology is the scientific study of microorganisms, those being unicellular, multicellular, or a cellular. Microbiology encompasses numerous sub-disciplines including virology, bacteriology, protozoology, mycology, immunology and parasitology.

Eukaryotic microorganisms possess membrane-bound organelles and include fungi and protests, whereas prokaryotic organisms—all of which are microorganisms—are conventionally classified as lacking membrane-bound organelles and include Bacteria and Achaea. Microbiologists traditionally relied on culture, staining, and microscopy. However, less than 1% of the microorganisms present in common environments can be cultured in isolation using current means.

Microbiologists often rely on molecular biology tools such as DNA sequence based identification, for example the 16S rRNA gene sequence used for bacteria identification.

Viruses have been variably classified as organisms, as they have been considered either as very simple microorganisms or very complex molecules. Prions, never considered as microorganisms, have been investigated by virologists, however, as the clinical effects traced to them were originally presumed due to chronic viral infections, and virologists took search—discovering "infectious proteins".

The existence of microorganisms was predicted many centuries before they were first observed, for example by the Jains in India and by Marcus Trendies Varro in ancient Rome. The first recorded microscope observation was of the fruiting bodies of moulds, by Robert Hooke in 1666, but the Jesuit priest Athanasius Kircher was likely the first to see microbes, which he mentioned observing in milk and putrid material in 1658. Antoine van Leeuwenhoek is considered a father of microbiology as he observed and experimented with microscopic organisms in the 1670s, using simple microscopes of his own design. Scientific microbiology developed in the 19th century through the work of Louis Pasteur and in medical microbiology Robert Koch.

History The existence of microorganisms was hypothesized for many centuries before their actual discovery. The existence of unseen microbiological life was postulated by Jainism which is based on Mahavira’s teachings as early as 6th century BCE. Paul Dundas notes that Mohair asserted the existence of unseen microbiological creatures living in earth, water, air and fire. Jain scriptures describe nigodas which are sub-microscopic creatures living in large clusters and having a very short life, said to pervade every part of the universe, even in tissues of plants and flesh of animals. The Roman Marcus Trendies Varro made references to microbes when he warned against locating a homestead in the vicinity of swamps "because there are bred certain minute creatures which cannot be seen by the eyes, which float in the air and enter the body through the mouth and nose and thereby cause serious diseases."

In the golden age of Islamic civilization, Persian scientists hypothesized the existence of microorganisms, such as Avicenna in his book The Canon of Medicine, Ibn Zuhr who discovered scabies mites, and Al-Razi who gave the earliest known description of smallpox in his book The Virtuous Life.

In 1546, Girolamo Fracastoro proposed that epidemic diseases were caused by transferable seedlike entities that could transmit infection by direct or indirect contact, or vehicle transmission.

In 1676, Antonie van Leeuwenhoek, who lived most of his life in Delft, Netherlands, observed bacteria and other microorganisms using a single-lens microscope of his own design. It has, however, been suggested that a Jesuit priest called Athanasius Kircher was the first to observe microorganisms.

Kircher was among the first to design magic lanterns for projection purposes, so he must have been well acquainted with the properties of lenses. Louis Pasteur and Robert Koch were contemporaries of Cohn, and are often considered to be the fathers of modern microbiology Pasteur is most famous for his series of experiments designed to disprove the then widely held theory of spontaneous generation, thereby solidifying microbiology's identity as a biological science.

One of his students, Adrien Certes, is considered the founder of marine microbiology. Pasteur also designed methods for food preservation and vaccines against several diseases such as anthrax, fowl cholera and rabies. While his work on the tobacco mosaic virus established the basic principles of virology, it was his development of enrichment culturing that had the most immediate impact on microbiology by allowing for the cultivation of a wide range of microbes with wildly different physiologies. Winogradsky was the first to develop the concept of chemolithotrophy and to thereby reveal the essential role played by microorganisms in geochemical processes. He was responsible for the first isolation and description of both nitrifying and nitrogen-fixing bacteria.

Joseph Lister was the first to use phenol disinfectant on the open wounds of patients.

Branches The branches of microbiology can be classified into applied sciences, or divided according to taxonomy, as is the case with bacteriology, mycology, protozoology, virology, phycology, and microbial ecology. There is considerable overlap between the specific branches of microbiology with each other and with other disciplines, and certain aspects of these branches can extend beyond the traditional scope of microbiology a pure research branch of microbiology is termed cellular microbiology.

Applications While some fear microbes due to the association of some microbes with various human diseases, many microbes are also responsible for numerous beneficial processes such as industrial fermentation, antibiotic production and act as molecular vehicles to transfer DNA to complex organisms such as plants and animals. Scientists have also exploited their knowledge of microbes to produce biotechnologically important enzymes such as Taq polymerase, reporter genes for use in other genetic systems and novel molecular biology techniques such as the yeast two-hybrid system.

Bacteria can be used for the industrial production of amino acids. Corynebacterium glutamicum is one of the most important bacterial species with an annual production of more than two million tons of amino acids, mainly L-glutamate and L-lysine. Since some bacteria have the ability to synthesize antibiotics, they are used for medicinal purposes, such as Streptomyces to make aminoglycoside antibiotics.

A variety of biopolymers, such as polysaccharides, polyesters, and polyamides, are produced by microorganisms.

Microorganisms are used for the biotechnological production of biopolymers with tailored properties suitable for highvalue medical application such as tissue engineering and drug delivery. Microorganisms are for example used for the biosynthesis of xanthan, alginate, cellulose, cyanophycin, poly, levan, hyaluronic acid, organic acids, oligosaccharides polysaccharide and polyhydroxyalkanoates.

Microorganisms are beneficial for microbial biodegradation or bioremediation of domestic, agricultural and industrial wastes and subsurface pollution in soils, sediments and marine environments. The ability of each microorganism to degrade toxic waste depends on the nature of each contaminant. Since sites typically have multiple pollutant types, the most effective approach to microbial biodegradation is to use a mixture of bacterial and fungal species and strains, each specific to the biodegradation of one or more types of contaminants.

Symbiotic microbial communities confer benefits to their human and animal host’s health including aiding digestion, producing beneficial vitamins and amino acids, and suppressing pathogenic microbes. Some benefit may be conferred by

eating fermented foods, probiotics or prebiotics. The ways the micro biome influences human and animal health, as well as methods to influence the microbiome are active areas of research.

Research has suggested that microorganisms could be useful in the treatment of cancer. Various strains of nonpathogenic clostridia can infiltrate and replicate within solid tumors. Clostridial vectors can be safely administered and their potential to deliver therapeutic proteins has been demonstrated in a variety of preclinical models.

Some bacteria are used to study fundamental mechanism. An example of model bacteria used to study motility or the production of polysaccharides and development is Myxococcus xanthus.

E. coli, they exposed each of the new plates to a bacteriophage. They observed that phage-resistant colonies were present at analogous locations on each of the plates, allowing them to conclude that the phage resistance trait had existed in the original colony, which had never been exposed to phage, instead of arising after the bacteria had been exposed to the virus.--> See also Biosafety Microbes and Man Professional organizations American Society for Microbiology Federation of European Microbiological Societies Society for General Microbiology Journals Critical Reviews in Microbiology International Journal of Systematic and Evolutionary Microbiology Journal of Bacteriology Nature Reviews Microbiology References Further reading Kreft, J.-U.; Plugge, C. M.; Grimm, V.; Prates, C.; Leveau, J. H. J. «» Proceedings of the National Academy of Sciences, 110, 45, 05-11-2013, peg. 18027–18028. DOI: 10.1073/pnas.1317472110. ISSN: 0027-8424. PMC: PMC3831448. PMID: 24194530.

Madigan M.T., Martinko J.M., Dunlap P-V., Clark D.P. 2009. Brock. Biología de los microorganismos. Pearson Educación, Madrid, pp. 1296 External links nature.com

Is a microbiology information portal containing a vast collection of resources including articles, news, frequently asked questions, and links pertaining to the field of microbiology?

Nutrition and die ticsNutrition is the biochemical and physiological process by which an organism uses food to support its life. It includes ingestion, absorption, assimilation, biosynthesis, catabolism and excretion.

The science that studies the physiological process of nutrition is called nutritional science .

Nutritional groups Organism primarily provide themselves with carbon in one of two ways: autotrophy and heterotrophy. Combined with the source of energy, either light or chemical, there are four primary nutritional groups for organisms.

Nutrients Nutrients are substances used by an organism to survive, grow, and reproduce. The seven major classes of relevant nutrients for animals are carbohydrates, fiber, fats, proteins, minerals, vitamins, and water. Nutrients can be grouped as either macronutrients or micronutrients.

Diet In nutrition, the diet of an organism is the sum of foods it eats, which is largely determined by the availability and palatability of foods.

Human nutrition Human nutrition deals with the provision of essential nutrients in food that are necessary to support human life and good health.

In humans, poor nutrition can cause deficiency-related diseases such as blindness, anemia, scurvy, preterm birth, stillbirth and cretinism, or nutrient excess health-threatening conditions such as obesity and metabolic syndrome; and such common chronic systemic diseases as cardiovascular disease, diabetes, and osteoporosis. Undernutrition can lead to wasting in acute cases, and the stunting of marasmus in chronic cases of malnutrition.

Plant nutrition Plant nutrition is the study of the chemical elements that are necessary for plant growth. There are several principles that apply to plant nutrition. Some elements are directly involved in plant metabolism. However, this principle does not account for the so-called beneficial elements, whose presence, while not required, has clear positive effects on plant growth.

A nutrient that is able to limit plant growth according to Liebig's law of the minimum is considered an essential plant nutrient if the plant cannot complete its full life cycle without it. There are 16 essential plant soil nutrients, besides the three major elemental nutrients carbon and oxygen that are obtained by photosynthetic plants from carbon dioxide in air, and hydrogen, which is obtained from water.

Plants uptake essential elements from the soil through their roots and from the air through their leaves. Green plants obtain their carbohydrate supply from the carbon dioxide in the air by the process of photosynthesis. Carbon and oxygen are absorbed from the air, while other nutrients are absorbed from the soil. Nutrient uptake in the soil is achieved by cation exchange, wherein root hairs pump hydrogen ions into the soil through proton pumps. These hydrogen ions displace cations attached to negatively charged soil particles so that the cations are available for uptake

by the root. In the leaves, stomata open to take in carbon dioxide and expel oxygen. The carbon dioxide molecules are used as the carbon source in photosynthesis.

Although nitrogen is plentiful in the Earth's atmosphere, very few plants can use this directly. Most plants, therefore, require nitrogen compounds to be present in the soil in which they grow. This is made possible by the fact that largely inert atmospheric nitrogen is changed in a nitrogen fixation process to biologically usable forms in the soil by bacteria.

Plant nutrition is a difficult subject to understand completely, partially because of the variation between different plants and even between different species or individuals of a given clone. Elements present at low levels may cause deficiency symptoms, and toxicity is possible at levels that are too high. Furthermore, deficiency of one element may present as symptoms of toxicity from another element, and vice versa.

See also Auxology Exercise Nutrition psychology Physical fitness References Bibliography Curley, S., and Mark . The Natural Guide to Good Health, Lafayette, Louisiana, Supreme Publishing.

OptometryOptometry is a health care profession that involves examining the eyes and applicable visual systems for defects or abnormalities as well as prescribing the correction of refractive error with glasses or contact lenses and the treatment of eye diseases.

Traditionally, the field of optometry began with the primary focus of correcting refractive error through the use of spectacles. Modern-day optometry, however, has evolved through time so that the educational curriculum additionally includes significant training in the diagnosis and management of ocular disease, in most of the countries of the world, where the profession is established and regulated.

Optometrists are health care professionals who usually provide primary eye care through comprehensive eye examinations. They diagnose and manage various vision abnormalities including refractive errors as well as various eye diseases. Being a regulated profession, an optometrist's scope of practice may differ depending on the location.

Optometrists typically work closely together with other eye care professionals such as ophthalmologists and opticians to deliver quality and efficient eye care to the general public.

Etymology The term "optometry" comes from the Greek words ὄψισ and μζτρον. The word entered the language when the instrument for measuring vision was called an optometric, . The root word opto is a shortened form derived from the Greek word ophthalmic meaning, "eye." Like most healthcare professions, the education and certification of optometrists are regulated in most countries. Optometric professionals and optometry-related organizations interact with governmental agencies, other healthcare professionals, and the community to deliver eye and vision care.

Definition of optometry and optometrist The World Council of Optometry, World Health Organization and about 75 optometry organisations from over 40 countries have all over the world adopted the following definition, to be used to describe optometry and optometrist. {{block quote Optometry is a healthcare profession that is autonomous, educated, and regulated, and optometrists are the primary healthcare practitioners of the eye and visual system who provide comprehensive eye and vision care, which includes refraction and dispensing, detection/diagnosis and management of disease in the eye, and the rehabilitation of conditions of the visual system.

Alternatively, research by David A. Goss in the United States shows they may have originated in the late 13th century in Italy as stated in a manuscript from 1305 where a monk from Pisa named Rivalto stated "It is not yet 20 years since there was discovered the art of making eyeglasses". Spectacles were manufactured in Italy, Germany, and the Netherlands by 1300. Needham stated spectacles were first made shortly after 1286.

In 1907, Professor Berthold Laufer, who was a German American anthropologist, stated in his history of spectacles 'the opinion that spectacles originated in India is of the greatest probability and that spectacles must have been known in India earlier than in Europe'. However, as already mentioned, Joseph Needham showed that the references Laufer cited were not in the older and best versions of the document Laufer used, leaving his claims unsupported.

In Sri Lanka, it is well-documented that during the reign of King Bhuvanekabahu the IV of the Gampola period the ancient tradition of optical lens making with a natural stone called Diyatarippu was given royal patronage. A few of the craftsmen still live and practice in the original hamlet given to the exponents of the craft by royal decree. But the date of King Bhuvanekabahu is decades after the mention of spectacles in the Venetian guild regulations and after the 1306

sermon by Dominican friar Giordano da Pisa, where da Pisa said the invention of spectacles was both recent and that he had personally met the inventor The German word brille is derived from Sanskrit vaidurya. Etymologically, brille is derived from beryl, Latin beryllus, from Greek beryllos, from Prakrit verulia, veluriya, from Sanskrit vaidurya, of Dravidian origin from the city of Velur . Medieval Latin berillus was also applied to eyeglasses, hence German brille, from Middle High German barilla, and French besicles spectacles, altered from old French bericle.

Benito Daza de Valdes published the first full book on opticians in 1623, where he mentioned the use and fitting of eyeglasses. In 1692, William Molyneux wrote a book on optics and lenses where he stated his ideas on myopia and problems related to close-up vision. The scientists Claudius Ptolemy and Johannes Kepler also contributed to the creation of optometry. Kepler discovered how the retina in the eye creates vision. From 1773 until around 1829, Thomas Young discovered the disability of astigmatism and it was George Bid dell Airy who designed glasses to correct that problem that included sphero-cylindrical lens.

Although the term optometric appeared in the 1759 book A Treatise on the Eye: The Manner and Phenomena of Vision

by Scottish physician William Porterfield, it was not until the early twentieth century in the United States and Australia that "optometry" began to be used to describe the profession. By the early twenty-first century, however, marking the distinction with dispensing opticians, it had become the internationally accepted term.

Training, licensing, representation and scope of practice Optometry is officially recognized in many jurisdictions. Most have regulations concerning education and practice.

Optometrists, like many other healthcare professionals, are required to participate in ongoing continuing education courses to stay current on the latest standards of care. The World Council of Optometry has a that provides basic information on eye care providers for more than 46 countries.

Africa In 1993 there were five countries in Africa with optometric teaching institutes: Sudan, Ghana, Nigeria, South Africa and Tanzania.

Sudan Sudan's major institution for the training of optometrists is the Faculty of Optometry and Visual Sciences, originally established in 1954 as the Institute of Optometry in Khartoum; the Institute joined with the Ministry of Higher Education in 1986 as the High Institute of Optometry, and ultimately was annexed into Alneelain University in 1997 when it was renamed to the FOVS. Currently, the FOVS has the following programs: 1) BSc optometry in 5 years with subspecialization in either orthoptics, contact lenses, ocular photography or ocular neurology; 2) BCs in ophthalmic technology, requiring four 4 years of training; and BCs in the optical dispensary, achieved in 4 years. The FOVS also offers MSc and PhD degrees in Optometry. The FOVS is the only institute of its kind in Sudan and was the first institution of higher education in Optometry in the Middle East and Africa. In 2010, Alneelain University Eye Hospital was established as part of the FOVS to expand training capacity and to serve broader Sudanese community.

Ghana The Ghana Optometric Association regulates the practice of Optometry in Ghana. After the six-year training at any of the two universities offering the course, the O.D degree is awarded. The new optometrist must write a qualifying exam, after which the optometrist is admitted as a member of the GOA, leading to the award of the title MGOA.

Mozambique The first optometry course in Mozambique was started in 2009 at Universidade Lurio, Nampula. The course is part of the Mozambique Eye care Project. University of Ulster, Dublin Institute of Technology and Brien Holden Vision Institute are supporting partners.

Nigeria In Nigeria, optometry is regulated by the Optometry and Dispensing Opticians Registration Board of Nigeria established under the Optometry and Dispensing Opticians Act of 1989 . The Boards publishes from time to time lists of approved qualifications and training institutions in the federal government gazette. The Doctor of Optometry degree is awarded after a six-year training at one of the accredited universities in Imo, Edo and Abia states.

Asia Bangladesh From 2010 Optometry was first introduced in Bangladesh in Institute of Community Ophthalmology Under Medicine Faculty of University of Chittagong http://icoedu.org. This institute offers a four years Bachelor of Science in Optometry course. Currently, there are 120 Graduated Optometrists in Bangladesh. The association which controls the quality of Optometry practice all over the country is named as 'Optometrists Association of Bangladesh' which is also a country member of World Council of Optometry.

In the year 2018, Chittagong Medical University formed and the Bsc. in Optometry course shifted to this University.

In Bangladesh, Optometrists perform primary eye care like Diagnosis and primary management of some ocular diseases, Prescribe Eye Glasses, Low vision rehabilitation, provide vision therapy, contact lens practice and all type of Orthoptic evaluations and management.

China In China, optometric education only began in 1988 at the Wenzhou Medical University. Since that time, the discipline and the profession have emerged as a five-year, medically-based program within the medical education system of China.

Students in the program receive the highest level of training in Optometry and are provided with the credentials needed to assume positions of leadership in China’s medical education and health care systems. In 2000, the Ministry of Health formally accepted Optometry as a subspecialty of medicine.

Hong Kong The Optometrists Board of the Supplementary Medical Professions Council regulates the profession in Hong Kong.

Optometrists are listed in separate parts of the register based on their training and ability. Registrants are subject to restrictions depending on the part they are listed in. Those who pass the examination on refraction conducted by the Board may be registered to Part III, thereby restricted to practice only work related to refraction. Those who have a Higher Certificate in Optometry or have passed the Board's optometry examination may be registered to Part II, thereby restricted in their use of diagnostic agents, but may otherwise practice freely. Part I optometrists may practice without restrictions and generally hold a bachelor's degree or a Professional Diploma.

There are around 2000 optometrists registered in Hong Kong, 1000 of which are Part I. There is one Part I optometrist to about 8000 members of the public. The Polytechnic University runs the only optometry school. It produces around 35 Part I optometrists a year.

India In 2010, it was estimated that India needs 115,000 optometrists; whereas India has approximately 9,000 optometrists and 40,000 optometric assistants/vision technicians . In order to prevent blindness or visual impairment more welltrained optometrists are required in India. The definition of optometry differs considerably in different countries of the world. India needs more optometry schools offering four-year degree courses with a syllabus similar to that in force in those countries where to practise of optometry is statutorily regulated and well established with an internationally accepted definition.

In 2013, it was reported in the Indian Journal of Ophthalmology that poor spectacle compliance amongst school children in rural Pune resulted in significant vision loss.

In 2015, it was reported in the Optometry and Vision Science that, optometrists need to be more involved in providing core optometry services like binocular vision and low vision.

Training in India At present, there are more than fifty schools of optometry in India. In the year 1958, two schools of optometry were established, one at Gandhi Eye Hospital, Aligarh in Uttar Pradesh and another one at Sarojini Devi Eye Hospital, Hyderabad in Telangana, under the second five-year plan by Director General of Health Services of Government of India.

These schools offered diplomas in optometry courses of two years duration validated by State Medical Faculties.

Subsequently, four more schools were opened across India situated at Sitapur Eye Hospital, Sitapur in Uttar Pradesh, Chennai in Tamil Nadu, Bengaluru in Karnataka and Regional Institute of Ophthalmology, Thiruvananthapuram in Kerala.

The Elite School of Optometry was established in 1985 at Chennai and was the first to offer a four-year degree course.

Academic degrees such as Bachelor of Optometry, Master of Optometry and Doctor of Philosophy in Optometry are awarded in India by the universities recognised by University Grants Commission, a statutory body responsible for the maintenance of standards of higher education in India.

Optometrists across India are encouraged to register with the Optometry Council of India, a self-regulatory body registered under the Indian Company Act. Malaysia It takes four years to complete a degree in Optometry. Today, optometry courses are well received by citizens. More universities and higher education studies are about to implement the courses, e.g., National Institute of Ophthalmic Sciences in Petaling Jaya whereby it is the academic arm of The Turn Hussein Onn National Eye Hospital. Other public universities that provide this course are University Kebangsaan Malaysia, Universiti Teknologi Mara, and International Islamic University Malaysia . There is also a private university that provides this course such as Management and Science University and SeGi University.

After completing the study in Degree in Optometry, the optometrist who practices in Malaysia must register under the Malaysian Optical Council which is the organization under the Ministry of Health.

The Association of Malaysian Optometrist is the only body that represents the Malaysian optometrist profession. All of the members are either local or overseas graduates in the field of Optometry.

Pakistan

Optometry is taught as a five/four-year Doctor/ Bachelors/ Bachelors with Honors course at many institutions notable among which are Department of Optometry & Vision Sciences FAHS, ICBS, Lahore, Pakistan Institute of Community Ophthalmology Peshawar, Pakistan institute of Rehabilitation science Isra University campus Islamabad, College of Ophthalmology & Allied Vision Sciences Lahore and Al-Shifa Institute of Ophthalmology Islamabad. After graduation, the optometrists can join a four-tiered service delivery level. MPhil in Optometry is also available at select institutions such as King Edward Medical University, Lahore Department of Optometry & Vision Sciences FAHS, ICBS, Lahore started bridging programmer for Bachelors/ Bachelors with Honors to become Doctor of Optometry OD, Post Professional Doctor of Optometry, Transitional Doctor of Optometry.

Optometry is not yet a regulated field in Pakistan as there is no professional licensing board or authority responsible for issuing practise licenses to qualified optometrists. This creates difficulty for Pakistani optometrists who wish to register abroad.

The University of Lahore has recently launched Doctor of optometry .

Imam Hussein Medical University also has launched Doctor of Optometry Program. Chairman Imam Hussain Medical University Dr Sabir Hussain Babachan has vowed to regulate OD curriculum according to international standard.

Philippines Optometry is regulated by the Professional Regulation Commission of the Philippines. To be eligible for licensing, each candidate must have satisfactorily completed a doctor of optometry course at an accredited institution and demonstrate good moral character with no previous record of professional misconduct. Professional organizations of optometry in the Philippines include Optometric Association of the Philippines and Integrated Philippine Association of Optometrists, Inc. .

Saudi Arabia In Saudi Arabia, optometrists must complete a five-year doctor of optometry degree from Qassim University and King Saud University also they must complete a two-year residency.

Singapore Tertiary education for optometrists takes 3 years at the following institutions.

Singapore Polytechnic - Diploma in Optometry Singapore Polytechnic Ngee Ann Polytechnic - Diploma in Optometry Ngee Ann Polytechnic Taiwan The education of Optometry in Taiwan commenced in 1982 at Shu-Zen College of Medicine and Management. Currently, Bcahelor degrees in Optometry can be obtained from seven universities : University of Kang Ning, Yuanpei University of Medical Technology, Asia University, Central Taiwan University of Science and Technology, Chung Shan Medical University, Dayeh University, and Chung Hwa University of Medical Technology; whereas Associate degrees in Optometry can be obtained from Mackay Junior College of Medicine, Nursing and Management, Hsin Sheng College of Medical Care and Management, Jen-Teh Junior College of Medicine, Nursing, and Management, and Shu-Zen College of Medicine and Management.

The Law of Optometrists was established in Taiwan in 2015, since then, Optometry students after obtaining Optometry degrees need to pass the National Optometry Examination of Taiwan to be registed as Optometrists. Currently, there are approximately 4,000 Optometrists in Taiwan, and around 400 new Optometrists rigister annunally .

Thailand Since late 1990, Thailand has set a goal to provide more than 600 optometrists to meet the minimal public demands and international standards in vision care. There are more than three university degree programs in Thailand. Each program accepts students that have completed grade 12th or the third year in high school . These programs offer "Doctor of Optometry" degree to graduates from the program that will take six years to complete the courses. Practising optometrists will also be required to pass licensing examination that is administrated through a committee under the Ministry of Public Health.

Nowadays, the number of practising optometrists in Thailand is still less than one hundred . However, it has projected that the number of practising optometrists in Thailand will greatly increase within the next ten years. In the theoretical scenario, the number of optometrists should be able to meet minimal public demands around 2030 or earlier.

Europe Since the formation of the European Union, "there exists a strong movement, headed by the Association of European Schools and Colleges of Optometry, to unify the profession by creating a European-wide examination for optometry" and presumably also standardized practice and education guidelines within EU countries. The first examinations of the new European Diploma in Optometry were held in 1998 and this was a landmark event for optometry in continental Europe.

France There is no regulatory framework and optometrists are sometimes trained by completing an apprenticeship at an ophthalmologists' private office.

Germany Optometric tasks are performed by ophthalmologists and professionally trained and certified opticians.

Greece Hellenic Ministry of Education founded the first department of Optometry at Technological Educational Institute of Patras in 2007. After protests from the department of Optics at Technological Educational Institute of Athens, the Government changed the names of the departments to "Optics and Optometry" and included lessons in both optics and optometry. Optometrists-Opticians have to complete a 4-year undergraduate honours degree. Then the graduates can be admitted to postgraduate courses in Optometry at universities around the world.

Since 2015, a Master of Science course in Optometry is offered by the Technological Educational Institute of Athens.

The Institute of Vision and Optics of the University of Crete focuses on the sciences of vision and is active in the fields of research, training, technology development and provision of medical services. Professor Ioannis Palikir’s has received numerous awards and recognitions for the Institute's contribution to ophthalmology. In 1989 he performed the first LASIK procedure on a human eye.

Hungary

Optometrist education takes 4 years in the medical universities in Hungary, and they will get a Bachelor of Science degree. They work in networks and retail stores and private optics, very few are located in the Health Care care system as ophthalmologists as an assistant.

Ireland The profession of Optometry has been represented for over a century by the Association of Optometrists, Ireland . In Ireland an optometrist must first complete a four-year degree in optometry at Dublin Institute of Technology. Following successful completion of the degree, an optometrist must then complete professional qualifying examinations to enter the register of the Opticians Board . Optometrists must be registered with the Board to practice in the Republic of Ireland.

The A.O.I. runs a comprehensive continuing education and professional development program on behalf of Irish optometrists. The legislation governing optometry was drafted in 1956. Some feel that the legislation restricts optometrists from using their full range of skills, training and equipment for the benefit of the Irish public. The amendment to the Act in 2003 addressed one of the most significant restrictions: the use of cycloplegic drugs to examine children.

Italy In Italy Optometry is an unregulated profession. It is taught at seven universities: Padua, Turin, Milan, Salento, Florence, Naples and Rome, as three years course of "Scienze e tecnologie fisiche" as a sector of the Physics Department.

Additionally, courses are available at some private institutions that offer advanced professional education for already qualified opticians . In the last thirty years several verdicts from High Court proof that optometry is a free practice and has truly education path.

Norway In Norway, the optometric profession has been regulated as a healthcare profession since 1988. After a three-year bachelor program, one can practice basic optometry. At least one year in clinical practice qualify for a post-degree halfyear sandwich course in contact lens fitting, which is regulated as a healthcare speciality. A separate regulation for the use of diagnostic drugs in optometric practice was introduced in 2004.

Russia In Russia, optometry education has been accredited by the Federal Agency of Health and Social Development.

There are only two educational institutions that teach optometry in Russia: Saint Petersburg Medical Technical College, formerly known as St. Petersburg College of Medical Electronics and Optics, and The Helmholtz Research Institute for Eye Diseases. They both belong and are regulated by the Ministry of Health. The optometry program is a four-year program. It includes one to two science foundation years, one year focused on clinical and proficiency skills, and one year of clinical rotations in hospitals. Graduates take college/state examinations and then receive a specialist diploma.

This diploma is valid for only five years and must be renewed every five years after receiving additional training at stateaccredited programs.

The scope of practice for optometrists in Russia includes refraction, contact lens fitting, spectacles construction and lens fitting, low vision aids, foreign body removal, referrals to other specialists after clinical condition diagnoses .

United Kingdom Licensing

Optometrists in the United Kingdom are regulated by the General Optical Council under the Opticians Act 1989 and distinguished from medical practitioners. Registration with the GOC is mandatory to practice optometry in the UK. Members of the College of Optometrists may use the suffix MCOptom.

The National Health Service provides free sight tests and spectacle vouchers for children and those on very low incomes.

The elderly and those with some chronic conditions like diabetes get free periodic tests. Treatment for eye conditions such as glaucoma and cataracts is free and checked for during normal eye examinations.

Training In the United Kingdom, optometrists have to complete a 3 or 4 year undergraduate honours degree followed by a minimum of a one-year "pre-registration period",, where they complete clinical practice under the supervision of a qualified and experienced practitioner. During this year the pre-registration candidate is given a number of quarterly assessments, often including temporary posting at a hospital, and on successfully passing all of these assessments, a final one-day set of examinations . Following successful completion of these assessments and having completed one year's supervised practice, the candidate is eligible to register as an optometrist with the General Optical Council and, should they so wish, are entitled to membership of the College of Optometrists. Twelve universities offer Optometry in the UK: Anglia Ruskin, Aston, Bradford, Cardiff, City, Glasgow Caledonian, Hertfordshire, Manchester, University of Plymouth, Ulster University at Coleraine, University of Portsmouth and University of the West of England.

In 2008 the UK moved forward to offer the Doctor of Optometry postgraduate program. This became available at the Institute of Optometry in London in partnership with London South Bank University. The Doctor of Optometry postgraduate degree is also offered at one other UK institution.Aston University Scope of Practice In 1990, a survey of the opinions of British medical practitioners regarding the services provided by British optometrists was carried out by Agarwal at City, University of London. A majority of respondents were in favour of optometrists extending their professional role by treating external eye conditions and prescribing broad-spectrum topical antibiotics through additional training and certification.

Since 2009, optometrists in the UK have been able to undertake additional postgraduate training and qualifications that allow them to prescribe medications to treat and manage eye conditions. There are currently three registerable specialities: Additional supply speciality - to write orders for, and supply in an emergency, a range of drugs in addition to those ordered or supplied by a normal optometrist.

Supplementary prescribing speciality - to manage a patient's clinical condition and prescribe medicines according to a clinical management plan set up in conjunction with an independent prescriber, such as a GP or ophthalmologist or qualified optometrist.

Independent prescribing specialty - to take responsibility for the clinical assessment of a patient, establish a diagnosis and determine the clinical management required, including prescribing where necessary.

North America Canada Training

In Canada, Doctors of Optometry typically complete four years of undergraduate studies followed by four to five years of optometry studies, accredited by the Accreditation Council on Optometric Education. There are two such schools of optometry located in Canada — the University of Waterloo and the University de Montreal. Canada also recognizes degrees from the twenty US schools.

Licensing In Canada, Doctors of Optometry must write national written and practical board exams. Additionally, optometrists are required to become licensed in the province in which they wish to practice. Regulation of professions is within provincial jurisdiction. Therefore, regulation of optometry is unique to individual provinces and territories. In Ontario, optometrists are licensed by the College of Optometrists of Ontario.

Representation In Canada, the profession is represented by the Canadian Association of Optometrists. In the province of Ontario, the Ontario Association of Optometrists is the designated representative of optometrists to the provincial government.

Scope of Practice Optometrists in Canada are trained and licensed to be primary eye care providers. They provide optical and medical eye care. They are able to diagnose and treat most eye diseases and can prescribe both topical and oral medications United States Optometrists are Doctors of Optometry who usually function as primary eye care providers. They provide comprehensive optical and medical eye care, but usually not surgery. They are trained and licensed to prescribe all topical medications, most oral medications, as well as administer diagnostic agents. In some states, optometrists may also be licensed to perform certain types of eye surgery.

Scope of Practice Optometrists are Doctors of Optometry who may prescribe corrective lenses to aid refractive errors. They manage vision development in children including amblyopia diagnosis/treatment. Some perform vision therapy. They are trained and state-licensed to diagnose and manage all eye diseases and their associations with systemic health. Optometrists can prescribe any topical medication and most oral medications including schedule controlled substances. Common eye conditions managed include infections, allergy, inflammation, diabetic/hypertensive retinopathy, macular degeneration etc. They may also remove ocular foreign bodies and can order blood panels or imaging studies. However, optometrists are not trained to perform invasive surgery like ophthalmologists are - which is the practical difference between the two professions, although in Oklahoma and Louisiana, optometrists may perform minor surgeries within the anterior segment of the eye. Moreover, legislation permits optometrists in Oklahoma and Kentucky to perform certain laser procedures. Optometrists may co-manage with other healthcare professionals when certain eye diseases are associated with underlying systemic causes e.g.: AIDS/HIV, neuro, rheumatology, oncology.

Ophthalmologists are Doctors of Medicine who usually provide speciality eye care - their training is heavily focused on surgery . In modern times, many Ophthalmologists choose to pursue fellowship training and specialize in one or more particular areas of the eye: e.g.: cornea, retina, glaucoma, strabismus, oculoplastics. Moreover, they typically deal with a late-stage eye disease which often can only be managed with surgery.

Opticians are not doctors; however, they are an important part of eye care. They are trained and licensed to cut, fit and adjust eyeglass frames/lenses. They are experts in lens types and wearing modalities: e.g. progressive, bifocal, single vision, lens index, coatings.

Regulation Doctors of optometry in the United States are regulated by state boards, which vary from state to state.

The Association of Regulatory Boards of Optometry assists these state board licensing agencies in regulating the practice of optometry.

Licensing Optometrists must complete all course work and graduate from an accredited College of Optometry. This includes passage of all parts of the national board examinations as well as local jurisprudence examinations, which vary by state.

Education and Training Doctors of Optometry typically complete four years of undergraduate studies followed by four years of Optometry school. Some complete an optional year of additional training. Optometry's program is highly specific to the eyes and related structures. Optometrists receive their medical eye training in optometry school. Training takes place in colleges of optometry, hospitals, clinics and private practices. Instructors may be optometrists, ophthalmologists, or professors.

The program includes classroom and clinical training in geometric, physical, physiological and ophthalmic optics, speciality contact lens evaluation, general anatomy, ocular anatomy, ocular disease, pharmacology, ocular pharmacology, neuroanatomical and neurophysiology of the visual system, pediatric visual development, gerontology, binocular vision, color vision, form, space, movement and vision perception, systemic disease, histology, microbiology, sensory and perceptual psychology, biochemistry, statistics and epidemiology.

Optometrists are required to obtain continuing education credit hours to maintain licensure.

Oceania Australia Australia currently has five recognized courses in optometry, and one course seeking to obtain accreditation with the Optometry council of Australia and New Zealand: Bachelor of Vision Science and Master of Optometry, Deakin University Bachelor of Medical Science and Master of Optometry, Flinders University Bachelor of Vision Science and Master of Clinical Optometry, University of New South Wales Bachelor of Vision Science and Master of Optometry, Queensland University of Technology Doctor of Optometry, Melbourne University Bachelor of Vision Science and Master of Optometry, University of Canberra To support these courses the Australian College of Optometry provides clinical placements to undergraduate students from Australian Universities and abroad.

in 2016, almost 5000 optometrists in general practice were licensed with their regulatory body, the . Of these, approximately 2300 were registered with the scheduled medicines endorsement, which enables them to prescribe some medicines for the treatment of conditions of the eye.

New Zealand New Zealand currently has one recognised course in optometry: Bachelor of Optometry, the University of Auckland In July 2014, the Medicines Amendment Act 2013 and Misuse of Drugs Amendment Regulations 2014 came into effect.

Among other things, the changes to the Act name optometrists as authorised prescribers. This change enables optometrists with a therapeutic pharmaceutical agent endorsement to prescribe all medicines appropriate to their scope of practice, rather than limiting them to a list of medicines specified in the regulation; this recognises the safe and appropriate prescribing practice of optometrists over the previous nine years.

South America Brazil The Brazilian Government does not state rules about optometry, and the Brazilian Council of Ophthalmology recommends against its official legal recognition.

The CBOO, which is affiliated to the WCO, represents Brazilian optometrists. In conjunction with organizations representative weight of Brazilian companies, including the National Commerce Confederation for goods, services and tourism, through the CBÓptica/CNC, its defence arm of the optometric and optical industry, are defending the right of free and independent practice of optometrists, even if it is against the interests of ophthalmologists.

The Federal Supreme Court, the Brazilian Court of Justice and the Superior Court of Justice, another important National Court, ruled several processes granting inquestionable victories to ophthalmologists.

In Brazilian law, however, there is an explicit recommendation that the one prescribing corrective lenses are prohibited to sell them. This restricting rule to the ophthalmologists has to keep the optic shops away from Hospitals and Eye Care Clinics since 1930, and it has to be reviewed before any further regulation for the optometrists.

Colombia In Colombia, optometry education has been accredited by the Ministry of Health. The last official revision to the laws regarding healthcare standards in the country was issued in 1992 through the Law 30. Currently there are eight official universities that are entitled by ICFES to grant the optometrist certification. The first optometrists arrived in the country from North America and Europe circa 1914. These professionals specialized in optics and refraction. In 1933, under Decrees 449 and 1291, the Colombian Government officially set the rules for the formation of professionals in the field of optometry. In 1966 La Salle University opened its first Faculty of Optometry after a recommendation from a group of professionals. At present optometrists are encouraged to keep up with new technologies through congresses and scholarships granted by the government or the private sector.

PharmacognosyPharmacognosy is the study of plants or other natural sources as a possible source of drugs. The American Society of Pharmacognosy defines pharmacognosy as "the study of the physical, chemical, biochemical, and biological properties of drugs, drug substances, or potential drugs or drug substances of natural origin as well as the search for new drugs from natural sources".

Description The word "pharmacognosy" is derived from two Greek words: φάρμακον pharmakon, and γνῶςισ gnosis or the Latin verb cognosco νϊςκω, ginόsko, meaning 'I know, perceive'), meaning 'to conceptualize' or 'to recognize'.

The term "pharmacognosy" was used for the first time by the Austrian physician Schmidt in 1811 and 1815 by Crr. Anotheus Seydler in work titled Analecta Pharmacognostica.

Originally—during the 19th century and the beginning of the 20th century—"pharmacognosy" was used to define the branch of medicine or commodity sciences which deals with drugs in their crude, or unprepared, form. Crude drugs are the dried, unprepared material of plant, animal or mineral origin, used for medicine. The study of these materials under the name pharmakognosie was first developed in German-speaking areas of Europe, while other language areas often used the older term materia medica taken from the works of Galen and Dioscorides. In German the term drogenkunde is also used synonymously.

As late as the beginning of the 20th century, the subject had developed mainly on the botanical side, being particularly concerned with the description and identification of drugs both in their whole state and in powder form. Such branches of pharmacognosy are still of fundamental importance, particularly for pharmacopoeial identification and quality control purposes, but rapid development in other areas has enormously expanded the subject. The advent of the 21st century brought a renaissance of pharmacognosy and its conventional botanical approach has been broadened up to molecular and metabolomic level.

In addition to the previously mentioned definition, the American Society of Pharmacognosy also defines pharmacognosy as "the study of natural product molecules that are useful for their medicinal, ecological, gustatory, or other functional properties." Other definitions are more encompassing, drawing on a broad spectrum of biological subjects, including botany, ethnobotany, marine biology, microbiology, herbal medicine, chemistry, biotechnology, phytochemistry, pharmacology, pharmaceutics, clinical pharmacy and pharmacy practice. medical ethnobotany: the study of the traditional use of plants for medicinal purposes; ethnopharmacology: the study of the pharmacological qualities of traditional medicinal substances; the study of phytotherapy ; and phytochemistry, the study of chemicals derived from plants .

Zoopharmacognosy, the process by which animals self-medicate, by selecting and using plants, soils, and insects to treat and prevent disease.

Marine pharmacognosy, the study of chemicals derived from marine organisms.

Biological background

All plants produce chemical compounds as part of their normal metabolic activities. These phytochemicals are divided into primary metabolites such as sugars and fats, which are found in all plants; and secondary metabolites— compounds which are found in a smaller range of plants, serving a more specific function. For example, some secondary metabolites are toxins used to deter predation and others are pheromones used to attract insects for pollination. It is these secondary metabolites and pigments that can have therapeutic actions in humans and which can be refined to produce drugs—examples are inulin from the roots of dahlias, quinine from the cinchona, THC and CBD from the flowers of cannabis, morphine and codeine from the poppy, and digoxin from the foxglove.

Alkaloids are a class of chemical compounds containing a nitrogen ring. Alkaloids are produced by a large variety of organisms, including bacteria, fungi, plants, and animals, and are part of the group of natural products . Many alkaloids can be purified from crude extracts by acid-base extraction. Many alkaloids are toxic to other organisms.

Polyphenols are compounds that contain phenol rings. The anthocyanins that give grapes their purple color, the isoflavones, the phytoestrogens from soy and the tannins that give tea its astringency are phenolics.

Glycosides are molecules in which a sugar is bound to a non-carbohydrate moiety, usually a small organic molecule.

Glycosides play numerous important roles in living organisms. Many plants store chemicals in the form of inactive glycosides. These can be activated by enzyme hydrolysis, which causes the sugar part to be broken off, making the chemical available for use.

Terpenes are a large and diverse class of organic compounds, produced by a variety of plants, particularly conifers, which are often strong smelling and thus may have had a protective function. They are the major components of resin, and of turpentine produced from resin. When terpenes are modified chemically, such as by oxidation or rearrangement of the carbon skeleton, the resulting compounds are generally referred to as terpenoids. Terpenes and terpenoids are the primary constituents of the essential oils of many types of plants and flowers. Essential oils are used widely as natural flavor additives for food, as fragrances in perfumery, and in traditional and alternative medicines such as aromatherapy. Synthetic variations and derivatives of natural terpenes and terpenoids also greatly expand the variety of aromas used in perfumery and flavors used in food additives. The fragrance of rose and lavender is due to monoterpenes. The carotenoids produce the reds, yellows and oranges of pumpkin, corn and tomatoes.

Natural products chemistry A typical protocol to isolate a pure chemical agent from natural origin is bioassay-guided fractionation, meaning step-bystep separation of extracted components based on differences in their physicochemical properties, and assessing the biological activity, followed by next round of separation and assaying. Typically, such work is initiated after a given crude drug formulation is deemed "active" in a particular in vitro assay. If the end-goal of the work at hand is to identify which one of the scores or hundreds of compounds are responsible for the observed in vitro activity, the path to that end is fairly straightforward: # fractionate the crude extract, e.g. by solvent partitioning or chromatography. # test the fractions thereby generated with in vitro assay. # repeat steps 1) and 2) until pure, active compounds are obtained. # determine structure of active compound, typically by using spectroscopic methods.

In vitro activity does not necessarily translate to activity in humans or other living systems.

Herbal

In some countries in Asia and Africa, 80% of the population relies on traditional medicine for primary health care. Native American cultures have also relied on traditional medicine such as ceremonial smoking of tobacco, potlatch ceremonies, and herbalism, to name a few, prior to European colonization. Knowledge of traditional medicinal practices is disappearing, particularly in the Amazon.

PhysiotherapyPhysical therapy, also known as physiotherapy, is one of the healthcare professions. Physical therapy is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, prognosis, patient education, physical intervention, rehabilitation, disease prevention and health promotion. Physical therapists are known as physiotherapists in many countries.

In addition to clinical practice, other aspects of physical therapist practice include research, education, consultation and health administration. Physical therapy is provided as a primary care treatment or alongside, or in conjunction with, other medical services. In some jurisdictions, such as the United Kingdom, physical therapists have the authority to prescribe medication.

Overview Physical therapy addresses the illnesses, or injuries that limit a person's abilities to move and perform functional activities in their daily lives. PTs use an individual's history and physical examination to arrive at a diagnosis and establish a management plan and, when necessary, incorporate the results of laboratory and imaging studies like X-rays, CT-scan, or MRI findings. Electro diagnostic testing may also be used. PT management commonly includes prescription of or assistance with specific exercises, manual therapy, and manipulation, mechanical devices such as traction, education, electro physical modalities which include heat, cold, electricity, sound waves, radiation, assistive devices, prostheses, orthoses, and other interventions. In addition, PTs work with individuals to prevent the loss of mobility before it occurs by developing fitness and wellness-oriented programs for healthier and more active lifestyles, providing services to individuals and populations to develop, maintain and restore maximum movement and functional ability throughout the lifespan. This includes providing therapeutic treatment in circumstances where movement and function are threatened by aging, injury, disease or environmental factors. Functional movement is central to what it means to be healthy.

Physical therapy is a professional career which has many specialties including musculoskeletal, orthopedics, cardiopulmonary, neurology, endocrinology, sports medicine, geriatrics, pediatrics, women's health, wound care and electromyography. Neurological rehabilitation is in particular a rapidly emerging field. PTs practice in many settings, such as private-owned physical therapy clinics, outpatient clinics or offices, health and wellness clinics, rehabilitation hospitals facilities, skilled nursing facilities, extended care facilities, private homes, education and research centers, schools, hospices, industrial and this workplaces or other occupational environments, fitness centers and sports training facilities.

Physical therapists also practice in the non-patient care roles such as health policy, health insurance, health care administration and as health care executives. Physical therapists are involved in the medical-legal field serving as experts, performing peer review and independent medical examinations.

Education varies greatly by country. The span of education ranges from some countries having little formal education to others having doctoral degrees and post-doctoral residencies and fellowships.

History Physicians like Hippocrates and later Galen are believed to have been the first practitioners of physical therapy, advocating massage, manual therapy techniques and hydrotherapy to treat people in 460 BC. After the development of orthopedics in the eighteenth century, machines like the Gymnastic on were developed to treat gout and similar diseases by systematic exercise of the joints, similar to later developments in physical therapy.

The earliest documented origins of actual physical therapy as a professional group date back to Per Henrik Ling, "Father of Swedish Gymnastics," who founded the Royal Central Institute of Gymnastics in 1813 for manipulation, and exercise.

Up until 2014, the Swedish word for a physical therapist was sjukgymnast someone involved in gymnastics for those who are ill, but the title was then changed to fysioterapeut, the word used in the other Scandinavian countries. In 1887, PTs were given official registration by Sweden's National Board of Health and Welfare. Other countries soon followed. In 1894, four nurses in Great Britain formed the Chartered Society of Physiotherapy. The School of Physiotherapy at the University of Otago in New Zealand in 1913, and the United States' 1914 Reed College in Portland, Oregon, which graduated "reconstruction aides." Since the profession's inception, spinal manipulative therapy has been a component of the physical therapist practice.

Modern physical therapy was established towards the end of the 19th century due to events that had an effect on a global scale, which called for rapid advances in physical therapy. Soon following American orthopedic surgeons began treating children with disabilities and began employing women trained in physical education, and remedial exercise.

These treatments were applied and promoted further during the Polio outbreak of 1916. During the First World War, women were recruited to work with and restore physical function to injured soldiers, and the field of physical therapy was institutionalized. In 1918 the term "Reconstruction Aide" was used to refer to individuals practicing physical therapy. The first school of physical therapy was established at Walter Reed Army Hospital in Washington, D.C., following the outbreak of World War I. Research catalyzed the physical therapy movement. The first physical therapy research was published in the United States in March 1921 in "The PT Review." In the same year, Mary McMillan organized the American Women's Physical Therapeutic Association . In 1924, the Georgia Warm Springs Foundation promoted the field by touting physical therapy as a treatment for polio.

Treatment through the 1940s primarily consisted of exercise, massage, and traction. Manipulative procedures to the spine and extremity joints began to be practiced, especially in the British Commonwealth countries, in the early 1950s.

Around the time that polio vaccines were developed, physical therapists became a normal occurrence in hospitals throughout North America and Europe. In the late 1950s, physical therapists started to move beyond hospital-based practice to outpatient orthopedic clinics, public schools, colleges/universities health-centres, geriatric settings, rehabilitation centers and medical centers. Specialization for physical therapy in the U.S. occurred in 1974, with the Orthopaedic Section of the APTA being formed for those physical therapists specializing in orthopaedics. In the same year, the International Federation of Orthopaedic Manipulative Physical Therapists was formed, which has ever since played an important role in advancing manual therapy worldwide.

Education Educational criteria for physical therapy providers vary from state to state and from country to country, and among various levels of professional responsibility. Most U.S. states have physical therapy practice acts that recognize both physical therapists and physical therapist assistants and some jurisdictions also recognize physical therapy technicians or aides. Most countries have licensing bodies that require physical therapists to be a member of before they can start practicing as independent professionals.

Canada Canadian physiotherapy programs are offered at 15 universities, often through the university's respective college of medicine. Each of Canada's physical therapy schools has transitioned from 3-year Bachelor of Science in Physical Therapy programs that required 2 years of prerequisite university courses to 2-year Masters of Physical Therapy programs that require prerequisite bachelor's degrees. The last Canadian university to follow suit was the University of Manitoba which transitioned to the MPT program in 2012, making the MPT credential the new entry to practice standard across Canada. Existing practitioners with BScPT credentials are not required to upgrade their qualifications.

In the province of Quebec, prospective physiotherapists are required to have completed a college diploma in either health sciences, which lasts on average two years, or physical rehabilitation technology, which lasts at least three years,

to apply to a physiotherapy program or program in university. Following admission, physical therapy students work on a bachelor of science with a major in physical therapy and rehabilitation. The B.Sc. usually requires three years to complete. Students must then enter graduate school to complete a master's degree in physical therapy, which normally requires one and a half to two years of study. Graduates who obtain their M.Sc. must successfully pass the membership examination to become member of the Ordre professionnel de la physiothérapie du Québec . Physiotherapists can pursue their education in such fields as rehabilitation sciences, sports medicine, kinesiology, and physiology.

In the province of Quebec, physical rehabilitation therapists are health care professionals who are required to complete a three-year college diploma program in physical rehabilitation therapy and be member of the Ordre professionnel de la physiothérapie du Québec in order to practise legally in the country.

Most physical rehabilitation therapists complete their college diploma at Collège Montmorency, Dawson College, or Cégep Marie-Victorin, all situated in and around the Montreal area.

After completing their technical college diploma, graduates have the opportunity to pursue their studies at the university level to perhaps obtain a bachelor's degree in physiotherapy, kinesiology, exercise science, or occupational therapy. The Université de Montréal, the University Laval and the Université de Sherbrooke are among the Québécois universities that admit physical rehabilitation therapists in their programs of study related to health sciences and rehabilitation in order to credit courses that were completed in college.

To date, there are no bridging programs available to facilitate upgrading from the BScPT to the MPT credential.

However, research Masters of Science and Doctor of Philosophy programs are available at every university. Aside from academic research, practitioners can upgrade their skills and qualifications through continuing education courses and curriculums. Continuing education is a requirement of the provincial regulatory bodies.

The Canadian Alliance of Physiotherapy Regulators offers eligible program graduates to apply for the national Physiotherapy Competency Examination. Passing the PCE is one of the requirements in most provinces and territories to work as a licensed physiotherapist in Canada. CAPR has members which are physiotherapy regulatory organizations recognized in their respective provinces and territories: Government of Yukon, Consumer Services College of Physical Therapists of British Columbia Physiotherapy Alberta College + Association Saskatchewan College of Physical Therapists College of Physiotherapists of Manitoba College of Physiotherapists of Ontario Ordre professionnel de la physiothérapie du Québec College of Physiotherapists of New Brunswick/Collège des physiotherapeutic du Nouveau-Brunswick Nova Scotia College of Physiotherapists Prince Edward Island College of Physiotherapists Newfoundland & Labrador College of Physiotherapists

The Canadian Physiotherapy Association offers a curriculum of continuing education courses in orthopaedics and manual therapy. The program consists of 5 levels of training with ongoing mentorship and evaluation at each level. The orthopaedic curriculum and examinations takes a minimum of 4 years to complete. However, upon completion of level 2, physiotherapists can apply to a unique 1-year course-based Master's program in advanced orthopaedics and manipulation at the University of Western Ontario to complete their training. This program accepts only 16 physiotherapists annually since 2007. Successful completion of either of these education streams and their respective examinations allows physiotherapists the opportunity to apply to the Canadian Academy of Manipulative Physiotherapy for fellowship. Fellows of the Canadian Academy of manipulative Physiotherapists are considered leaders in the field, having extensive post-graduate education in orthopaedics and manual therapy. FCAMPT is an internationally recognized credential, as CAMPT is a member of the International Federation of Manipulative Physiotherapists, a branch of the World Confederation of Physical Therapy and the World Health Organization .

Scotland Physiotherapy degrees are offered at three universities: Robert Gordon University in Aberdeen, Glasgow Caledonian University in Glasgow and Queen Margaret University in Edinburgh. Students can qualify as physiotherapists by completing a four-year Bachelor of Science degree or a two-year master's degree .

In order to use the title 'Physiotherapist', a student must register with the Health and Care Professions Council, a UK wide regulatory body, on qualifying. Many physiotherapists are also members of the Chartered Society of Physiotherapists, who provides insurance and professional support.

United States The primary physical therapy practitioner is the Physical Therapist who is trained and licensed to examine, evaluate, diagnose and treat impairment, functional limitations and disabilities in patients or clients. Physical therapist education curricula in the United States culminate in a Doctor of Physical Therapy degree, with some practicing PTs holding a Master of Physical Therapy degree, and some with a Bachelor's degree. The Master of Physical Therapy and Master of Science in Physical Therapy degrees are no longer offered, and the entry-level degree is the Doctor of Physical Therapy degree, which typically takes 3 years after completing bachelor's degree. PTs who hold a Masters or bachelors in PT are encouraged to get their DPT because APTA's goal is for all PT's to be on a doctoral level. WCPT recommends physical therapist entry-level educational programs be based on university or university-level studies, of a minimum of four years, independently validated and accredited. Curricula in the United States are accredited by the Commission on Accreditation in Physical Therapy Education . According to CAPTE, as of 2017 there are 31,380 students currently enrolled in 227 accredited PT programs in the United States while 12,945 PTA students are currently enrolled in 331 PTA programs in the United States.

The physical therapist professional curriculum includes content in the clinical sciences. Current training is specifically aimed to enable physical therapists to appropriately recognize and refer non-musculoskeletal diagnoses that may presently similarly to those caused by systems not appropriate for physical therapy intervention, which has resulted in direct access to physical therapists in many states.

Post-doctoral residency and fellowship education prevalence is increasing steadily with 219 residency, and 42 fellowship programs accredited in 2016. Residencies are aimed to train physical therapists in a specialty such as acute care, cardiovascular & pulmonary, clinical electrophysiology, faculty, geriatrics, neurology, orthopaedics, pediatrics, sports, women's health, and wound care, whereas fellowships train specialists in a subspecialty, similar to the medical model.

Residency programs offer eligibility to sit for the specialist certification in their respective area of practice. For example, completion of an orthopedic physical therapy residency, allows its graduates to apply and sit for the clinical specialist examination in orthopedics, achieving the OCS designation upon passing the examination. Board certification of physical

therapy specialists is aimed to recognize individuals with advanced clinical knowledge and skill training in their respective area of practice, and exemplifies the trend toward greater education to optimally treat individuals with movement dysfunction.

Physical therapist assistants may deliver treatment and physical interventions for patients and clients under a care plan established by and under the supervision of a physical therapist. Physical therapist assistants in the United States are currently trained under associate of applied sciences curricula specific to the profession, as outlined and accredited by CAPTE. As of August 2011, there were 276 accredited two-year programs for physical therapist assistants In the United States of America. According to CAPTE, as of 2012 there are 10,598 students currently enrolled in 280 accredited PTA programs in the United States.

Anatomy & physiology Exercise physiology Human biology Physics Biomechanics Kinesiology Neuroscience Clinical pathology Behavioral sciences Communication Ethics Research Other coursework as required by individual programs.

Job duties and education requirements for Physical Therapy Technicians or Aides may vary depending on the employer, but education requirements range from high school diploma or equivalent to completion of a 2-year degree program. ONet reports that 64% of PT Aides/Techs have a high school diploma or equivalent, 21% have completed some college but do not hold a degree, and 10% hold an associate degree.

Some jurisdictions allow physical therapists to employ technicians or aides or therapy assistants to perform designated routine tasks related to physical therapy under the direct supervision of a physical therapist. Some jurisdictions require physical therapy technicians or aides to be certified, and education and certification requirements vary among jurisdictions.

Employment Physical therapy-related jobs in North America have shown rapid growth in recent years, but employment rates and average wages may vary significantly between different countries, states, provinces or regions. A study from 2013 states that 56.4% of physical therapists were globally satisfied with their jobs. Salary, interest in work, and fulfillment in job are important predictors of job satisfaction. Emotional exhaustion is significantly higher among physical therapists working

with adults and employed in hospitals. Other factors that increased burnout include working in a hospital setting and having seniority from 15 to 19 years. The Bureau of Labor Statistics also reports that there were approximately 128,700 Physical Therapist Assistants and Aides employed in the United States in 2014, earning an average $42,980 annually, or $20.66 per hour, with 40% growth in employment projected by the year 2024. To meet their needs, many healthcare and physical therapy facilities hire "travel physical therapists", who work temporary assignments between 8 and 26 weeks for much higher wages; about $113,500 a year. Bureau of Labor Statistics data on PTAs and Techs can be difficult to decipher, due to their tendency to report data on these job fields collectively rather than separately. O-Net reports that in 2015, PTAs in the United States earned a median wage of $55,170 annually or $26.52 hourly, and that Aides/Techs earned a median wage of $25,120 annually or $12.08 hourly in 2015. The American Physical Therapy Association reports vacancy rates for physical therapists as 11.2% in outpatient private practice, 10% in acute care settings, and 12.1% in skilled nursing facilities. The APTA also reports turnover rates for physical therapists as 10.7% in outpatient private practice, 11.9% in acute care settings, 27.6% in skilled nursing facilities.

Specialty areas The body of knowledge of physical therapy is large, and therefore physical therapists may specialize in a specific clinical area. While there are many different types of physical therapy, the American Board of Physical Therapy Specialties lists ten current specialist certifications. Most Physical Therapists practicing in a specialty will have undergone further training, such as an accredited residency program, although individuals are currently able to sit for their specialist examination after 2,000 hours of focused practice in their respective specialty population, in addition to requirements set by each respective specialty board.

Cardiovascular and pulmonary Cardiovascular and pulmonary rehabilitation respiratory practitioners and physical therapists offer therapy for a wide variety of cardiopulmonary disorders or pre and post cardiac or pulmonary surgery. An example of cardiac surgery is coronary bypass surgery. Primary goals of this specialty include increasing endurance and functional independence.

Manual therapy is used in this field to assist in clearing lung secretions experienced with cystic fibrosis. Pulmonary disorders, heart attacks, post coronary bypass surgery, chronic obstructive pulmonary disease, and pulmonary fibrosis, treatments can benefit from cardiovascular and pulmonary specialized physical therapists. Other commonly used interventions include exercise, edema control, splinting, and compression garments. The work done by physical therapists in the integumentary specialty do work similar to what would be done by medical doctors or nurses in the emergency room or triage.

Neurology Neurological physical therapy is a field focused on working with individuals who have a neurological disorder or disease.

These can include stroke, chronic back pain, Alzheimer's disease, Charcot-Marie-Tooth disease, ALS, brain injury, cerebral palsy, multiple sclerosis, Parkinson's disease, facial palsy and spinal cord injury. Common impairments associated with neurologic conditions include impairments of vision, balance, ambulation, activities of daily living, movement, muscle strength and loss of functional independence. The techniques involve in neurological physical therapy are wide-ranging and often require specialized training.

Neurological physiotherapy is also called neurophysiotherapy or neurological rehabilitation. It is recommended for neurophysiotherapists to collaborate with psychologists when providing physical treatment of movement disorders. This is especially important because combining physical therapy and psychotherapy can improve neurological status of the patients.

Orthopaedics

Orthopedic physical therapists diagnose, manage, and treat disorders and injuries of the musculoskeletal system including rehabilitation after orthopedic surgery. acute trauma such as sprains, strains, injuries of insidious onset such as tendinopathy, bursitis and deformities like scoliosis. This speciality of physical therapy is most often found in the outpatient clinical setting. Orthopedic therapists are trained in the treatment of post-operative orthopedic procedures, fractures, acute sports injuries, arthritis, sprains, strains, back and neck pain, spinal conditions, and amputations.

Joint and spine mobilization/manipulation, dry needling, therapeutic exercise, neuromuscular techniques, muscle reeducation, hot/cold packs, and electrical muscle stimulation are modalities employed to expedite recovery in the orthopedic setting. Additionally, an emerging adjunct to diagnosis and treatment is the use of sonography for diagnosis and to guide treatments such as muscle retraining. Those who have suffered injury or disease affecting the muscles, bones, ligaments, or tendons will benefit from assessment by a physical therapist specialized in orthopedics.

Pediatrics Pediatric physical therapy assists in early detection of health problems and uses a variety of modalities to provide physical therapy for disorders in the pediatric population. These therapists are specialized in the diagnosis, treatment, and management of infants, children, and adolescents with a variety of congenital, developmental, neuromuscular, skeletal, or acquired disorders/diseases. Treatments focus mainly on improving gross and fine motor skills, balance and coordination, strength and endurance as well as cognitive and sensory processing/integration.

Sports Physical therapists are closely involved in the care and wellbeing of athletes including recreational, semi-professional and professional participants. This area of practice encompasses athletic injury management under 5 main categories: # acute care – assessment and diagnosis of an initial injury; # treatment – application of specialist advice and techniques to encourage healing; # rehabilitation – progressive management for full return to sport; # prevention – identification and address of deficiencies known to directly result in, or act as precursors to injury, such as movement assessment # education – sharing of specialist knowledge to individual athletes, teams or clubs to assist in prevention or management of injury Physical therapists who work for professional sport teams often have a specialized sports certification issued through their national registering organisation. Most Physical therapists who practice in a sporting environment are also active in collaborative sports medicine programs too .

Women's health Women's health or pelvic floor physical therapy mostly addresses women's issues related to the female reproductive system, child birth, and post-partum. These conditions include lymphedema, osteoporosis, pelvic pain, prenatal and post-partum periods, and urinary incontinence. It also addresses incontinence, pelvic pain, and other disorders associated with pelvic floor dysfunction. Manual physical therapy has been demonstrated in multiple studies to increase rates of conception in women with infertility.

Oncology

Physical therapy in the field of oncology and palliative care is a continuously evolving and developing specialty, both in malignant and non-malignant diseases. Physical therapy for both groups of patients is now recognized as an essential part of the clinical pathway, as early diagnoses and new treatments are enabling patients to live longer. it is generally accepted that patients should have access to an appropriate level of rehabilitation, so that they can function at a minimum level of dependency and optimize their quality of life, regardless of their life expectancy.

Physical therapist–patient collaborative relationship A systematic review that included patients with brain injury, musculoskeletal conditions, cardiac conditions, or multiple pathologies found that the alliance between patient and therapist positively correlates with treatment outcome.

Outcomes includes: ability to perform activities of daily living, manage pain, complete specific physical function tasks, depression, global assessment of physical health, treatment adherence, and treatment satisfaction.

Studies have explored four themes that may influence patient–therapist interactions: interpersonal and communication skills, practical skills, individualized patient-centered care, and organizational and environmental factors. Practical skills such as the ability to educate patients about their conditions, and professional expertise are perceived as valuable factors in patient care. Patients value the ability of a clinician to provide clear and simple explanations about their problems. Furthermore, patients value when physical therapists possess excellent technical skills that improve the patient effectively.

Environmental factors such as the location, equipment used, and parking are less important to the patient than the physical therapy clinical encounter itself.

Based on the current understanding, the most important factors that contribute to the patient–therapist interactions include that the physical therapist: spends an adequate amount of time with the patient, possesses strong listening and communication skills, treats the patient with respect, provides clear explanations of the treatment, and allows the patient to be involved in the treatment decisions. According to randomized control trials, a combination of manual therapy and supervised exercise therapy by physiotherapists give functional benefits for patients with osteoarthritis of the knee, and may delay or even prevent the need for surgery. Another randomized controlled study has shown that surgical decompression treatment and physiotherapy are on par for lumbar spinal stenosis in improving symptoms and function. Several studies have suggested that physical therapy, particularly manual therapy techniques focused on the neck and the median nerve, combined with stretching exercises, may be equivalent or even preferable to surgery for Carpal Tunnel Syndrome. A 2015 systematic review suggested that while spine manipulation and therapeutic massage are effective interventions for neck pain, electroacupuncture, strain-counterstrain, relaxation massage, heat therapy, and ultrasound therapy are not as effective, and thus not recommended.

Studies also show physical therapy is effective for patients with other conditions. A 2012 systematic review about the effectiveness of physiotherapy treatment in asthma patients concluded that physiotherapy treatment may improve quality of life, promote cardiopulmonary fitness and inspiratory pressure, as well as reduce symptoms and medication use. Physical therapy is sometimes provided to patients in the ICU, as early mobilization can help reduce ICU and hospital length of stay and improve long-term functional ability. A 2013 systematic review showed that early progressive mobilization for adult, intubated ICU patients on mechanical ventilation is safe and effective.

Results from a 2019 systematic review suggest that psychologically informed physical therapy, where a physical therapist treats patients while other members of a multidisiplinary care team help in preoperative planning for patient management of pain and quality of life helps improve patient outcomes. This is especially present in when utilized before and after spine, hip, or knee surgery.

Telehealth

Telehealth is a developing form of physical therapy in response to the increasing demand for physical therapy treatment. Telehealth is online communication between the clinician and patient, either live or in pre-recorded sessions with mixed reviews when compared to usual, in-person care. The benefits of telehealth include improved accessibility in remote areas, cost efficiency, and improved convenience for the bedridden and home-restricted, physically disabled.

Studies are controversial as to the effectiveness of telehealth in patients with more serious conditions, such as stroke, multiple sclerosis, and lower back pain.

During the COVID-19 pandemic, the need for telehealth came to the fore as patients were less able to safely attend inperson, particularly if the were elderly or had chronic diseases. Telehealth was considered to be a proactive step to prevent decline in individuals that could not attend classes. Physical decline in at risk groups is difficult to address or undo later. The platform licensing or development are found to be the most substantial cost in telehealth. Telehealth does not remove the need for the physical therapist as they still need to oversee the program.

United States Definitions and licensing requirements in the United States vary among jurisdictions, as each state has enacted its own physical therapy practice act defining the profession within its jurisdiction, but the Federation of State Boards of Physical Therapy has also drafted a model definition in order to limit this variation. The Commission on Accreditation in Physical Therapy Education is responsible for accrediting physical therapy education curricula throughout the United States of America.

United Kingdom The title of Physiotherapist is a protected professional title in the United Kingdom. Anyone using this title must be registered with the Health & Care Professions Council. Physiotherapists must complete the necessary qualifications, usually an undergraduate physiotherapy degree, a master rehabilitation degree or a doctoral degree in physiotherapy.

This is typically followed by supervised professional experience lasting two to three years. All professionals on the HCPC register must comply with continuing professional development and can be audited for this evidence at intervals.

Speech therapySpeech–language pathology is a field of expertise practiced by a clinician known as a speech–language pathologist or a speech and language therapist, both of whom may be known by the shortened description, speech therapist. Speech– language pathology is considered a "related health profession" or "allied health profession", along with audiology, optometry, occupational therapy, rehabilitation psychology, physical therapy, behavior analysis and others.

SLPs specialize in the evaluation, diagnosis, and treatment of communication disorders, cognitive-communication disorders, voice disorders, and swallowing disorders. SLPs also play an important role in the diagnosis and treatment of autism spectrum disorder .

The profession Speech–language pathologists provide a wide range of services, mainly on an individual basis, but also as support for individuals, families, support groups, and providing information for the general public. SLPs work to prevent, assess, diagnose, and treat speech, language, social communication, cognitive-communication, voice, fluency, and swallowing disorders in children and adults. Speech services begin with initial screening for communication and swallowing disorders and continue with assessment and diagnosis, consultation for the provision of advice regarding management, intervention, and treatment, and providing counseling and other follow-up services for these disorders. Services are provided in the following areas: cognitive aspects of communication . speech ; language including comprehension and expression in oral, written, graphic, and manual modalities; language processing; preliteracy and language-based literacy skills, phonological awareness. augmentative and alternative communication, for individuals with severe language and communication impairments.

Swallowing or other upper aerodigestive functions such as infant feeding and aeromechanical events; Voice, poor vocal volume, abnormal vocal quality. Research demonstrates voice therapy to be especially helpful with certain patient populations; individuals with Parkinson's Disease often develop voice issues as a result of their disease.

Sensory awareness related to communication, swallowing, or other upper aerodigestive functions.

Speech, language, and swallowing disorders result from a variety of causes, such as a stroke, brain injury, hearing loss, developmental delay, a cleft palate, cerebral palsy, or emotional issues.

A common misconception is that speech–language pathology is restricted to the treatment of articulation disorders and/or the treatment of individuals who stutter but, in fact, speech–language pathology is concerned with a broad scope of speech, language, literacy, swallowing, and voice issues involved in communication, some of which include: Word-finding and other semantic issues, either as a result of a specific language impairment such as a language delay or as a secondary characteristic of a more general issue such as dementia.

Social communication difficulties involving how people communicate or interact with others .

Language impairments, including difficulties creating sentences that are grammatical and modifying word meaning .

Literacy impairments related to the letter-to-sound relationship, the word-to-meaning relationship, and understanding the ideas presented in a text .

Voice difficulties, such as a raspy voice, a voice that is too soft, or other voice difficulties that negatively impact a person's social or professional performance.

Cognitive impairments to the extent that they interfere with communication.

The components of speech production include: phonation, resonance, fluency, intonation, pitch variance; voice.

The components of language include: Phonology; Morphology; Syntax, semantics; Pragmatics.

Primary pediatric speech and language disorders include: receptive and expressive language disorders, speech sound disorders, childhood apraxia of speech, stuttering, and language-based learning disabilities. Speech pathologists work with people of all ages.

Swallowing disorders include difficulties in any system of the swallowing process, as well as functional dysphagia and feeding disorders. Swallowing disorders can occur at any age and can stem from multiple causes. Another area of collaboration relates to auditory processing disorders, where SLPs can collaborate in assessments and provide intervention where there is evidence of speech, language, and/or other cognitive-communication disorders.

Working environments SLPs work in a variety of clinical and educational settings. SLPs work in public and private hospitals, private practices, skilled nursing facilities, long-term acute care facilities, hospice, and home healthcare. SLPs may also work as part of the support structure in the education system, working in public and private schools, colleges, and universities. Some SLPs also work in community health, providing services at prisons and young offenders' institutions or providing expert testimony in applicable court cases.

Following the American Speech–Language–Hearing Association's 2005 approval of the delivery of speech/language services via video conference or telepractice, SLPs in the United States have begun to use this service model.

Research SLPs conduct research related to communication sciences and disorders, swallowing disorders, or other upper aerodigestive functions.

Education and training United States In the United States, speech–language pathology is a Master's entry-level professional degree field. Clinicians must hold a master's degree in communicative disorders / speech–language pathology that is from a university that holds regional accreditation and from a communication sciences and disorders program that is accredited by the American Speech– Language–Hearing Association, the profession's national governing body as well as individual state's governing board.

Programs that offer the mEd degree are often housed within a university's College of education, but offer the same education and training as programs with a MA or MS degree. Beyond the master's degree, some SLPs may choose to earn a clinical doctorate in speech–language pathology, or a doctoral degree that has a research and/or professional focus . All degrees must be from a university that holds regional accreditation, but only the master's degree is accredited by the ASHA.

All clinicians are required to complete 400 clinical hours. They must pass multiple comprehensive exams also called Knowledge and Skills Acquisition exams.

After all the above requirements have been met during the SLP's path to earning the graduate degree, SLPs must state licensure and national certification by: Passing the National Speech–Language Pathology Board examination .

Successfully complete a clinical fellowship year as a clinical fellow under the mentorship of a fully licensed mentor clinician. The CFY is no less than 36 weeks of full-time experience, totaling a minimum of 1260 hours. During the CFY, the CF cannot earn CFY hours unless they work more than 5 hours in a week and cannot earn any CFY hours beyond 35 hours in a week.

Receive American Speech–Language–Hearing Association Certificate of Clinical Competence and full state licensure to practice, following successful completion of clinical fellowship year.

States are responsible for licensure of clinicians and other professionals and, as far as the new SLP, these requirements are often similar to that of the CFY. Following the state licensure procedures and national certification requirements are usually done simultaneously.

To maintain licensure, SLPs are required to participate in periodic earning of Continuing Educational Units . Continuing education and training obligations: Educate, supervise, and mentor future SLPs. Participate in continuing education.

Educate and provide in-service training to families, caregivers, and other professionals.

Train, supervise, and manage speech–language pathology assistants and other support personnel.

Educating and counseling individuals, families, co-workers, educators, and other persons in the community regarding acceptance, adaptation, and decisions about communication and swallowing.

Professional suffix: Credentials of a clinical fellow typically read as: MA, MS, or MEd, CF-SLP. Credentials of a fully licensed SLP commonly read as: MA, MS, or MEd, CCC-SLP, indicating a practitioner's graduate degree and successful completion of the fellowship year/board exams to obtain the "three Cs" the Certification of Clinical Competence, in speech–language pathology.

Salary information Salaries of SLPs in the United States depend on a variety of factors including educational background, work experience, and location. The ASHA 2016 Schools Survey revealed that SLPs received a median academic year salary of $62,000, which is a 2% increase from the latest Schools Survey done in 2014. The 2015 SLP Health Care Survey placed the median salary for SLPs working within the health care industry at $75,000. According to the Bureau of Labor Statistics in 2019, the median salary for SLP in the US is $79,120. In Australia, the basic salary that a Graduate SLP would earn is estimated at AU$59,500 and around AU$55,000 for a private SLP. Methods of assessment

For many parents, the decision of whether or not to enroll students into school-based speech therapy or privately practiced therapy is challenging. Speech Pathologists work as part of a team alongside teachers, counselors, social workers and parents when in a school setting. Because school-based speech therapy is run under state guidelines and funds, the process of assessment and qualification is more strict. To qualify for in-school speech therapy, students must meet the state's criteria on language testing and speech standardization. Due to such requirements, some students may not be assessed in an efficient time frame or their needs may be undermined by criteria. For a private clinic, students are more likely to qualify for therapy because it is a paid service with more availability.

Clients and patients Speech–language pathologists work with clients and patients who may present with a wide range of issues.

Infants and children Infants with injuries due to complications at birth, feeding and swallowing difficulties, including dysphagia Children with mild, moderate or severe: Genetic disorders that adversely affect speech, language and/or cognitive development including cleft palate, Down syndrome, DiGeorge syndrome Attention deficit hyperactivity disorder Autism spectrum disorders, including Asperger syndrome Developmental delay Feeding disorders, including oral motor deficits Cranial nerve damage Hearing loss Craniofacial anomalies that adversely affect speech, language and/or cognitive development Language delay Specific language impairment Specific difficulties in producing sounds, called articulation disorders, Pediatric traumatic brain injury Developmental verbal dyspraxia Cleft palate United States In the US, some children are eligible to receive speech therapy services, including assessment and lessons through the public school system. If not, private therapy is readily available through personal lessons with a qualified speech– language pathologist or the growing field of telepractice. Teleconferencing tools such as Skype are being used more commonly as a means to access remote locations in private therapy practice, such as in the geographically diverse south island of New Zealand. More at-home or combination treatments have become readily available to address specific

types of articulation disorders. The use of mobile applications in speech therapy is also growing as an avenue to bring treatment into the home.

United Kingdom In the UK, children are entitled to an assessment by local NHS speech- and language-therapy teams, usually after referral by health visitors or education settings, but parents are also entitled to request an assessment directly. If treatment is appropriate, an educational plan will be drawn up. Speech therapists often play a role in multi-disciplinary teams when a child has speech delay or disorder as part of a wider health condition. The Children's Commissioner for England reported in June 2019 that there was a postcode lottery; £291.65 a year per head was spent on services in some areas, while the budget in some areas was £30.94 or less. In 2018, 193,971 children in English primary schools were on the special educational needs register needing speech-therapy services.

Children and adults Puberphonia Cerebral palsy Head injury Hearing loss and impairments Learning difficulties including Dyslexia Specific language impairment Auditory processing disorder Physical disabilities Speech disorders Stammering, stuttering Stroke Voice disorders Language delay Motor speech disorders Naming difficulties Dysgraphia, agraphia Cognitive communication disorders Pragmatics Laryngectomies

Tracheostomies Oncology Adults Adults with mild, moderate, or severe eating, feeding and swallowing difficulties, including dysphagia Adults with mild, moderate, or severe language difficulties as a result of: Motor neuron diseases, Alzheimer's disease, Dementia, Huntington's disease, Multiple sclerosis, Parkinson's disease, Traumatic brain injury, Mental health issues Stroke Progressive neurological conditions such as cancer of the head, neck and throat Aphasic Adults seeking transgender-specific voice training, including voice feminization and voice masculinization See also Puberphonia All India Institute of Speech and Hearing AIIMS, New Delhi American Speech–Language–Hearing Association Applied linguistics Auditory processing disorder Augmentative and alternative communication Communicative disorders assistant Esophageal speech Frenkel exercises

Language delay List of university speech–language pathology departments List of voice disorders Motor theory of speech perception Neurolinguistics Oral myology Origin of speech Phonation Paragrammatism Specific language impairment Speech acquisition Speech and language pathology in school settings Speech perception Speech processing Speech repetition.

AyurvedaAyurveda is an alternative medicine system with historical roots in the Indian subcontinent. The theory and practice of Ayurveda is pseudoscientific. Ayurveda is heavily practiced in India and Nepal, where around 80% of the population report using it. Medicines are typically based on complex herbal compounds, minerals, and metal substances . Ancient Ayurveda texts also taught surgical techniques, including rhinoplasty, kidney stone extractions, sutures, and the extraction of foreign objects.

The main classical Ayurveda texts begin with accounts of the transmission of medical knowledge from the gods to sages, and then to human physicians. In Sushruta Samhita, Sushruta wrote that Dhanvantari, Hindu god of Ayurveda, incarnated himself as a king of Varanasi and taught medicine to a group of physicians, including Sushruta. Ayurveda has been adapted for Western consumption, notably by Baba Hari Dass in the 1970s and Maharishi Ayurveda in the 1980s.

Some scholars assert that Ayurveda originated in prehistoric times, and that some of the concepts of Ayurveda have existed from the time of the Indus Valley Civilization or even earlier. Ayurveda developed significantly during the Vedic period and later some of the non-Vedic systems such as Buddhism and Jainism also developed medical concepts and practices that appear in the classical Ayurveda texts.

There is no good evidence that Ayurveda is effective for treating any disease. substances known to be harmful to humans. In a 2008 study, close to 21% of U.S. and Indian-manufactured patent Ayurvedic medicines sold through the Internet were found to contain toxic levels of heavy metals, specifically lead, mercury, and arsenic. The public health implications of such metallic contaminants in India are unknown. This characterization of the physicians' art, "the medicine that has eight components", is first found in the Sanskrit epic the Mahabharata, c. 4th century BCE. The components are: Kāyachikitsā: general medicine, medicine of the body Kaumāra-bhṛtya: Discussions about prenatal and postnatal care of baby and mother, methods of conception; choosing the child's gender, intelligence, and constitution; and childhood diseases and midwifery. Śalyatantra: surgical techniques and the extraction of foreign objects Śhālākyatantra: treatment of ailments affecting ears, eyes, nose, mouth, etc.

Bhūtavidyā: pacification of possessing spirits, and the people whose minds are affected by such possession Agadatantra/Vishagara-vairodh Tantra : It includes subjects about epidemics, toxins in animals, vegetables and minerals.

It as well contain keys for recognizing those anomalies and their antidotes.

Rasāyantantra: rejuvenation and tonics for increasing lifespan, intellect and strength Vājīkaraṇatantra: aphrodisiacs and treatments for increasing the volume and viability of semen and sexual pleasure. It also deals with infertility problems and spiritual development.

Principles and terminology The word "Ayurveda" is,, meaning knowledge of life and longevity.

The central theoretical ideas of Ayurveda developed in the mid-first millennium BCE, and show parallels with Swanky and Vaiśeṣika philosophies, as well as with Buddhism and Jainism. Balance is emphasized, and suppressing natural urges

is considered unhealthy and claimed to lead to illness. However, people are also cautioned to stay within the limits of reasonable balance and measure when following nature's urges. sleep, and sexual intercourse.

According to ayurveda, the human body is composed of tissues, waste, and biomaterials .

The three elemental bodily humors, the doshas or tridosha, are vata, pitta, and kapha. A parallel set of mental doshas termed satogun, rajogun, and tamogun control psychology. Each dosha has particular attributes and roles within the body and mind; the natural predominance of one or more doshas thus explains a person's physical constitution and personality. Ayurvedic tradition holds that imbalance among the bodily and mental doshas is a major etiologic component of disease. One Ayurvedic view is that the doshas are balanced when they are equal to each other, while another view is that each human possesses a unique combination of the doshas which define this person's temperament and characteristics. In either case, it says that each person should modulate their behavior or environment to increase or decrease the doshas and maintain their natural state. Practitioners of Ayurveda must determine an individual's bodily and mental dosha makeup, as certain prakriti are said to predispose one to particular diseases. Deranged vata is also associated with certain mental disorders due to excited or excess vayu, although the Ayurvedic text Charaka Samhita also attributes "insanity" to cold food and possession by the ghost of a sinful Brahman .

Ama is used to refer to the concept of anything that exists in a state of incomplete transformation. With regards to oral hygiene, it is claimed to be a toxic byproduct generated by improper or incomplete digestion. The concept has no equivalent in standard medicine.

In medieval taxonomies of the Sanskrit knowledge systems, Ayurveda is assigned a place as a subsidiary Veda . Some medicinal plant names from the Atharvaveda and other Vedas can be found in subsequent Ayurveda literature. The earliest recorded theoretical statements about the canonical models of disease in Ayurveda occur in the earliest Buddhist Canon.

Practice Ayurvedic practitioners regard physical existence, mental existence, and personality as their own unique units, with each element being able to influence the others. This is a holistic approach used during diagnosis and therapy, and is a fundamental aspect of Ayurveda. Another part of Ayurvedic treatment says that there are channels which transport fluids, and that the channels can be opened up by massage treatment using oils and Swedana . Unhealthy, or blocked, channels are thought to cause disease.

Diagnosis Ayurveda has eight ways to diagnose illness, called Nadi, Mootra, Mala, Jihva, Shabda, Sparsha, Druk, and Aakruti .

Ayurvedic practitioners approach diagnosis by using the five senses. For example, hearing is used to observe the condition of breathing and speech. One type of prescription is a Sattvic diet.

Ayurveda follows the concept of Dinacharya, which says that natural cycles are important for health. Hygiene, including regular bathing, cleaning of teeth, oil pulling, tongue scraping, skin care, and eye washing, is also a central practice.

Animal products used in Ayurveda include milk, bones, and gallstones. In addition, fats are prescribed both for consumption and for external use. Consumption of minerals, including sulphur, arsenic, lead, copper sulfate and gold, are also prescribed. which are said to adjust the doshas by increasing Pitta and reducing Vatta and Kapha. is used in eight Ayurvedic preparations and is said to balance the Vata and Kapha doshas and increase the Pitta dosha. It is possible that opium was brought to India along with or before Muslim conquests. The book Yoga Ratnakara, which is popular in Maharashtra, uses opium in a herbal-mineral composition prescribed for diarrhea. and oil pulling. Liquids may also be poured on the patient's forehead, a technique called shirodhara.

Panchakarma According to Ayurveda, panchakarma are techniques to eliminate toxic elements from the body.

Current status India According to some sources, up to 80 percent of people in India use Ayurveda exclusively or combined with conventional Western medicine.

In 1970, the Indian Medical Central Council Act which aimed to standardise qualifications for Ayurveda practitioners and provide accredited institutions for its study and research was passed by the Parliament of India. The Indian government supports research and teaching in Ayurveda through many channels at both the national and state levels, and helps institutionalise traditional medicine so that it can be studied in major towns and cities. The state-sponsored Central Council for Research in Ayurvedic Sciences is designed to do research on Ayurveda. Many clinics in urban and rural areas are run by professionals who qualify from these institutes., India has over 180 training centers offer degrees in traditional Ayurvedic medicine. The formulations come from over 100 traditional Ayurveda books.

An Indian Academy of Sciences document quoting a 2003-04 report states that India had 432,625 registered medical practitioners, 13,925 dispensaries, 2,253 hospitals and a bed strength of 43,803. 209 under-graduate teaching institutions and 16 post-graduate institutions. Insurance companies cover expenses for Ayurvedic treatments in case of conditions such as spinal cord disorders, bone disorder, arthritis and cancer. Such claims constitute 5-10 percent of the country's health insurance claims.

Maharashtra Andhashraddha Nirmoolan Samiti, an organisation dedicated to fighting superstition in India, considers Ayurveda to be pseudoscience.

On 9 November 2014, India formed the Ministry of AYUSH. National Ayurveda Day is also observed in India on the birth of Dhanvantari that is Dhanteras.

Other countries on the Indian subcontinent About 75%-80% of the population of Nepal use Ayurveda and it is the most practiced form of medicine in the country.

The Sri Lankan tradition of Ayurveda is similar to the Indian tradition. Practitioners of Ayurveda in Sri Lanka refer to Sanskrit texts which are common to both countries. However, they do differ in some aspects, particularly in the herbs used.

In 1980, the Sri Lankan government established a Ministry of Indigenous Medicine to revive and regulate Ayurveda. The Institute of Indigenous Medicine offers undergraduate, postgraduate, and MD degrees in Ayurveda Medicine and Surgery, and similar degrees in unani medicine. In the public system, there are currently 62 Ayurvedic hospitals and 208 central dispensaries, which served about 3 million people in 2010. In total, there are about 20,000 registered practitioners of Ayurveda in the country.

According to the Mahavamsa, an ancient chronicle of Sinhalese royalty from the sixth century C.E., King Pandukabhaya of Sri Lanka had lying-in-homes and Ayurvedic hospitals built in various parts of the country. This is the earliest documented evidence available of institutions dedicated specifically to the care of the sick anywhere in the world.

Mihintale Hospital is the oldest in the world.

Outside the Indian subcontinent

Ayurveda is a system of traditional medicine developed during antiquity and the medieval period, and as such is comparable to pre-modern Chinese and European systems of medicine. However, beginning in the 1960s, Ayurveda has been advertised as alternative medicine in the Western world. Due to different laws and medical regulations in the rest of the world, the unregulated practice and commercialisation of Ayurveda have raised ethical and legal issues. In some instances, Ayurvedic practices or terminology have also been adapted specifically for Western consumption, notably in the case of "Maharishi Ayurveda" in the 1980s. In some cases, this involved active fraud on the part of proponents of Ayurveda in an attempt to falsely represent the system as equal to the standards of modern medical research.

Baba Hari Dass was an early proponent who helped bring Ayurveda to the US in the early 1970s. He taught classes derived from the Suśrutha Saṃhitā and the Charaka Saṃhitha, leading to the establishment of the Mount Madonna Institute, College of Ayurveda, Ayurveda World, and Ayurvedic pharmacy. He invited several notable Ayurvedic teachers, including Vasant Lad, Sarita Shrestha, and Ram Harsh Singh. The Ayurvedic practitioner Michael Tierra wrote that "he history of Ayurveda in North America will always owe a debt to the selfless contributions of Baba Hari Dass."

In the United States, the practice of Ayurveda is not licensed or regulated by any state. The National Center for Complementary and Integrative Health says that "Few well-designed clinical trials and systematic research reviews suggest that Ayurvedic approaches are effective", warns against the issue of heavy metal poisoning, and emphasises the use of conventional health providers first.

Classification and efficacy Although laboratory experiments suggest it is possible that some substances in Ayurveda might be developed into effective treatments, there is no evidence that any are effective in themselves. Cancer Research UK states that there is no evidence that ayurvedic medicine helps treat cancer in people, and some Ayurvedic drugs contain toxic substances or interact with legitimate cancer drugs in a harmful way.

Ayurvedic medicine is considered pseudoscientific because it confuses reality and metaphysical concepts, and because its premises are not based on science. Ethnologist Johannes Quack writes than although the rationalist movement Maharashtra Andhashraddha Nirmoolan Samiti officially labels Ayurveda – like astrology – a pseudoscience, these practices are in fact embraced by many of the movement's members.

A review of the use of Ayurveda for cardiovascular disease concluded that the evidence is not convincing for the use of any Ayurvedic herbal treatment for heart disease or hypertension, but that many herbs used by Ayurvedic practitioners could be appropriate for further research.

Research into ayurveda has been characterized as pseudoscience. Both the lack of scientific soundness in the theoretical foundations of ayurveda and the quality of research have been criticized.

Research In India, research in Ayurveda is undertaken by the Ministry of AYUSH, an abbreviation for the Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy, through a national network of research institutes.

In Nepal, the National Ayurvedic Training and Research Centre researches medicinal herbs in the country.

In Sri Lanka, the Ministry of Health, Nutrition and Indigenous Medicine looks after the research in Ayurveda through various national research an institute.

Use of toxic metals

Rasa shastra, the practice of adding metals, minerals or gems to herbal preparations, may include toxic heavy metals such as lead, mercury and arsenic.

Some traditional Indian herbal medicinal products contain harmful levels of heavy metals, including lead. A 1990 study on Ayurvedic medicines in India found that 41% of the products tested contained arsenic, and that 64% contained lead and mercury. A 2008 study of more than 230 products found that approximately 20% of remedies purchased over the Internet from U.S. and Indian suppliers contained lead, mercury or arsenic. A 2015 study of users in the United States found elevated blood lead levels in 40% of those tested, leading physician and former U.S. Air Force flight surgeon Harriet Hall to say that "Ayurveda is basically superstition mixed with a soupçon of practical health advice. And it can be dangerous."

Heavy metals are thought of as active ingredients by advocates of Indian herbal medicinal products. According to ancient Ayurvedic texts, certain physico-chemical purification processes such as samskaras or shodhanas 'detoxify' the heavy metals in it. These are similar to the Chinese pao zhi, although the Ayurvedic techniques are more complex and may involve physical pharmacy techniques as well as mantras. However, these products have nonetheless caused severe lead poisoning and other toxic effects. In 2012, the U.S. Centers for Disease Control and Prevention linked Ayurvedic drugs to lead poisoning, based on cases where toxic materials were found in the blood of pregnant women who had taken Ayurvedic drugs.

Ayurvedic practitioners argue that the toxicity of bhasmas comes from improper manufacturing processes, contaminants, improper use of Ayurvedic medicine, quality of raw materials and that the end products and improper procedures are used by charlatans. However, in Current Science, a publication of the Indian Academy of Sciences, M. S. Valiathan said that "the absence of post-market surveillance and the paucity of test laboratory facilities make the quality control of Ayurvedic medicines exceedingly difficult at this time". A 2012 toxicological review of mercury-based traditional herbo-metallic preparations concluded that the long-term pharmacotherapeutic and in-depth toxicity studies of these preparations are lacking.

History According to modern Ayurvedic sources, the origins of Ayurveda have been traced to around 6,000 BCE when they originated as an oral tradition. Some of the concepts of Ayurveda have existed since the times of Indus Valley Civilization. The first recorded forms of Ayurveda as medical texts evolved from the Vedas. this contains 114 hymns and incantations described as magical cures for disease. There are various legendary accounts of the origin of Ayurveda, e.g. that it was received by Dhanvantari from Brahma. Tradition also holds that the writings of Ayurveda were influenced by a lost text by the sage Agonies.

Ayurveda is one of the few systems of medicine developed in ancient times that is still widely practiced in modern times.

As such, it is open to the criticism that its conceptual basis is obsolete and that its contemporary practitioners have not taken account of the developments of modern medicine. Responses to this situation led to an impassioned debate in India during the early decades of the twentieth century, between proponents of unchanging tradition and those who thought ayurveda should modernise and syncretize . The political debate about the place of ayurveda in contemporary India has continued to the present, both in the public arena and in government. Debate about the place of Ayurvedic medicine in the contemporary internationalized world also continues today .

Main texts There are three principal early texts on Ayurveda, the Charaka Samhita, the Sushruta Samhita and the Bhela Samhita.

The dating of these works is historically complicated since they each internally present themselves as composite works compiled by several editors. All past scholarship on their dating has been evaluated by Meulenbeld in volumes IA and IB

of his History of Indian Medical Literature. but has long since been overturned by subsequent historical research. The current consensus amongst medical historians of South Asia is that the Suśrutasaṃhitā was compiled over a period of time starting with a kernel of medical ideas from the century or two BCE and then being revised by several hands into its present form by about 500 CE. has been disproved, although the last chapter of the work, the Uttaratantra, was added by an unknown later author before 500 CE. but are in fact, in their present form, datable to a period between the second and fifth centuries CE. The Bower Manuscript includes of excerpts from the Bheda Samhita and its description of concepts in Central Asian Buddhism. In 1987, A. F. R. Hoernle identified the scribe of the medical portions of the manuscript to be a native of India using a northern variant of the Gupta script, which had migrated and become a Buddhist monk in a monastery in Kucha.

The Chinese pilgrim Fa Hsien wrote about the healthcare system of the Gupta empire and described the institutional approach of Indian medicine. This is also visible in the works of Charaka, who describes hospitals and how they should be equipped.

Other early texts are the Agnivesha Samhita, Kasyapa Samhita and Harita Samhita. The original edition of the Agnivesha Samhita, by Agnivesa, is dated to 1500 BCE, and it was later modified by Charaka. Kasyapa Samhita includes the treatise of Jivaka Kumar Bhaccha and is dated to the 6th century BCE. While Harita Samhita is dated to an earlier period, it is attributed to Harita, who was a disciple of Punarvasu Atreya. Some later texts are Astanga nighantu by Vagbhata, Paryaya ratnamala by Madhava, Siddhasara nighantu by Ravi Gupta, Dravyavali, and Dravyaguna sangraha by Chakrapani Datta, among others.

Illnesses portrayed Underwood and Rhodes state that the early forms of traditional Indian medicine identified fever, cough, consumption, diarrhea, dropsy, abscesses, seizures, tumours, and leprosy, and stitching of wounds. During this period, treatments were also prescribed for complex ailments, including angina pectoris, diabetes, hypertension, and stones.

Further development and spread Ayurveda flourished throughout the Indian Middle Ages. Dalhana, Sarngadhara and Bhavamisra compiled works on Indian medicine. The medical works of both Sushruta and Charaka were also translated into the Chinese language in the 5th century, and during the 8th century, they were translated into the Arabic and Persian language. The 9th-century Persian physician Muhammad ibn Zakariya al-Razi was familiar with the text. The Arabic works derived from the Ayurvedic texts eventually also reached Europe by the 12th century. In Renaissance Italy, the Branca family of Sicily and Gaspare Tagliacozzi were influenced by the Arabic reception of the Sushruta's surgical techniques. Instruments described in the Sushruta Samhita were further modified in Europe. Joseph Constantine Carpue studied plastic surgery methods in India for 20 years and, in 1815, was able to perform the first major rhinoplasty surgery in the western world, using the "Indian" method of nose reconstruction. In 1840 Brett published an article about this technique.

During the period of British colonial rule in India, the practice of Ayurveda was not adopted by the British Indian Government, which was in favor of modern medicine. After Indian independence, there was more focus on Ayurveda and other traditional medical systems. Ayurveda became a part of the Indian National health care system, with state hospitals for Ayurveda established across the country. However, the treatments of traditional medicines were not always integrated with others.

Footnotes See also Acupuncture

Asians Bachelor of Ayurveda, Medicine and Surgery Bhaisajyaguru Dhātu History of alternative medicine Homeopathy List of ineffective cancer treatments Ramuan References Cited references Further reading Pattathu, Anthony George . Ayurveda and Discursive Formations between Religion, Medicine and Embodiment: A Case Study from Germany. In: Lüddeckens, D., & Schrimpf, M. . . Bielefeld: transcript Verlag., pp. 133–166. . A bibliographical survey of the history of Indian medicine.

- US Food and Drug Administration.

HomeopathyHomeopathy or homoeopathy is a pseudoscientific system of alternative medicine. It was conceived in 1796 by the German physician Samuel Hahnemann. Its practitioners, called homeopaths, believe that a substance that causes symptoms of a disease in healthy people can cure similar symptoms in sick people; this doctrine is called similia similibus curentur, or "like cures like". Between each dilution homeopaths may hit and/or shake the product, claiming this makes the diluent remember the original substance after its removal. Practitioners claim that such preparations, upon oral intake, can treat or cure disease.

All relevant scientific knowledge about physics, chemistry, biochemistry and biology gained since at least the mid-19th century Hahnemann's theory of disease, centered around principles he termed miasms, is inconsistent with subsequent identification of viruses and bacteria as causes of disease. Clinical trials have been conducted and generally demonstrated no objective effect from homeopathic preparations. The fundamental implausibility of homeopathy as well as a lack of demonstrable effectiveness has led to it being characterized within the scientific and medical communities as quackery and fraud.

Homeopathy achieved its greatest popularity in the 19th century. It was introduced to the United States in 1825 with the first homeopathic school opening in 1835. Throughout the 19th century, dozens of homeopathic institutions appeared in Europe and the United States. During this period, homeopathy was able to appear relatively successful, as other forms of treatment could be harmful and ineffective. By the end of the century the practice began to wane, with the last exclusively homeopathic medical school in the US closing in 1920.

In the 1970s, homeopathy made a significant comeback, with sales of some homeopathic products increasing tenfold.

The trend corresponded with the rise of the New Age movement, and may be in part due to an irrational preference for "natural" products, and the longer consultation times homeopathic practitioners provided.

In the 21st century a series of meta-analyses have shown that the therapeutic claims of homeopathy lack scientific justification. As a result, national and international bodies have recommended the withdrawal of government funding for homeopathy in healthcare. National bodies from Australia, the United Kingdom, Switzerland and France, as well as the European Academies' Science Advisory Council and the Russian Academy of Sciences have all concluded that homeopathy is ineffective, and recommended against the practice receiving any further funding. The National Health Service in England no longer provides funding for homeopathic remedies and asked the Department of Health to add homeopathic remedies to the list of forbidden prescription items. France removed funding in 2021, while Spain has also announced moves to ban homeopathy and other pseudotherapies from health centers.

History Homeopathy, the longest established alternative medicine to come out of Europe, was created in 1796 by Samuel Hahnemann. Hahnemann rejected the mainstream medicine of the late 18th century as irrational and inadvisable because it was largely ineffective and often harmful. He advocated the use of single drugs at lower doses and promoted an immaterial, vitalistic view of how living organisms function. The term homeopathy was coined by Hahnemann and first appeared in print in 1807. He also coined the expression "allopathic medicine", which was used to pejoratively refer to traditional Western medicine.

Concept Hahnemann conceived of homeopathy while translating a medical treatise by the Scottish physician and chemist William Cullen into German. Being sceptical of Cullen's theory that cinchona cured malaria because it was bitter, Hahnemann ingested some bark specifically to investigate what would happen. He experienced fever, shivering and joint pain:

symptoms similar to those of malaria itself. From this, Hahnemann came to believe that all effective drugs produce symptoms in healthy individuals similar to those of the diseases that they treat, in accord with the "law of similars" that had been proposed by ancient physicians. This led to the name "homeopathy", which comes from the hómoios, "-like" and pathos, "suffering". s The law of similars doctrine is called similia similibus curentur, or "like cures like". An account of the effects of eating cinchona bark noted by Oliver Wendell Holmes, published in 1861, failed to reproduce the symptoms Hahnemann reported.

Proving Hahnemann began to test what effects various substances may produce in humans, a procedure later called "homeopathic proving". These tests required subjects to test the effects of ingesting substances by recording all their symptoms as well as the ancillary conditions under which they appeared. He published a collection of provings in 1805, and a second collection of 65 preparations appeared in his book, Materia Medica Pura .

As Hahnemann believed that large doses of drugs that caused similar symptoms would only aggravate illness, he advocated for extreme dilutions. A technique was devised for making dilutions that Hahnemann claimed would preserve the substance's therapeutic properties while removing its harmful effects. Hahnemann believed that this process enhanced "the spirit-like medicinal powers of the crude substances". He gathered and published an overview of his new medical system in his book, The Organon of the Healing Art, with 6th edition published in 1921 still used by homeopaths today.

Miasms and disease In the Organon, Hahnemann introduced the concept of "miasms" as the "infectious principles" underlying chronic disease and as "peculiar morbid derangement of vital force". Hahnemann associated each miasm with specific diseases, and thought that initial exposure to miasms causes local symptoms, such as skin or venereal diseases. His assertion was that if these symptoms were suppressed by medication, the cause went deeper and began to manifest itself as diseases of the internal organs. The underlying imputed miasm still remains, and deep-seated ailments can be corrected only by removing the deeper disturbance of the vital force.

Hahnemann's hypotheses for miasms originally presented only three local symptoms: psora, syphilis or sycosis . Of these the most important was psora, described as being related to any itching diseases of the skin and was claimed to be the foundation of many further disease conditions. Hahnemann believed it to be the cause of such diseases as epilepsy, cancer, jaundice, deafness, and cataracts. Since Hahnemann's time, other miasms have been proposed, some replacing illnesses previously attributed to the psora, including tuberculosis and cancer miasms.

Hahnemann's miasm theory remains disputed and controversial within homeopathy even in modern times. The theory of miasms has been criticized as an explanation developed to preserve the system of homeopathy in the face of treatment failures, and for being inadequate to cover the many hundreds of sorts of diseases, as well as for failing to explain disease predispositions, as well as genetics, environmental factors, and the unique disease history of each patient.

19th century: rise to popularity and early criticism Homeopathy achieved its greatest popularity in the 19th century. It was introduced to the United States in 1825 by Hans Birch Gram, a student of Hahnemann. The first homeopathic school in the United States opened in 1835 and the American Institute of Homeopathy was established in 1844. Throughout the 19th century, dozens of homeopathic institutions appeared in Europe and the United States, and by 1900, there were 22 homeopathic colleges and 15,000

practitioners in the United States. Though ineffective, homeopathic preparations are rarely detrimental, thus users are less likely to be harmed by the treatment that is supposed to be helping them. One reason for the growing popularity of homeopathy was its apparent success in treating people suffering from infectious disease epidemics. During 19thcentury epidemics of diseases such as cholera, death rates in homeopathic hospitals were often lower than in conventional hospitals, where the treatments used at the time were often harmful and did little or nothing to combat the diseases.

Even during its rise in popularity, homeopathy was criticized by scientists and physicians. Sir John Forbes, physician to Queen Victoria, said in 1843 that the extremely small doses of homeopathy were regularly derided as useless and considered it "an outrage to human reason". James Young Simpson said in 1853 of the highly diluted drugs: "No poison, however strong or powerful, the billionth or decillionth of which would in the least degree affect a man or harm a fly."

19th-century American physician and author Oliver Wendell Holmes was also a vocal critic of homeopathy and published an essay entitled Homœopathy and Its Kindred Delusions . The last school in the US exclusively teaching homeopathy closed in 1920. Unschuld also states that homeopathy never subsequently took root in the United States, but remained more deeply established in European thinking. In the United States, the Food, Drug, and Cosmetic Act of 1938 recognized homeopathic preparations as drugs. In the 1950s, there were only 75 solely homeopathic practitioners in the U.S. By the mid to late 1970s, homeopathy made a significant comeback and sales of some homeopathic companies increased tenfold.

Some homeopaths credit for the revival to Greek homeopath George Vithoulkas, who conducted a "great deal of research to update the scenarios and refine the theories and practice of homeopathy" in the 1970s, but Ernst and Simon Singh consider it to be linked to the rise of the New Age movement.

Towards the end of the century opposition to homeopathy began to increase again; with William T. Jarvis, the President of the National Council Against Health Fraud, saying that "Homeopathy is a fraud perpetrated on the public with the government's blessing, thanks to the abuse of political power of Sen. Royal S. Copeland."

21st century Since the beginning of the 21st century, a series of meta-analyses have further shown that the therapeutic claims of homeopathy lack scientific justification. This had lead to a decrease or suspension of funding by many governments. In a 2010 report, the Science and Technology Committee of the United Kingdom House of Commons recommended that homeopathy should no longer receive National Health Service funding due its lack of scientific credibility; The federal government only ended up accepting three of the 45 recommendations made by the 2018 review of Pharmacy Remuneration and Regulation. The same year the US Food and Drug Administration held a hearing requesting public comment on the regulation of homeopathic drugs. In 2017 the FDA announced it would strengthen regulation of homeopathic products.

The American non-profit Center for Inquiry filed a lawsuit in 2018 against the CVS pharmacy for consumer fraud over its sale of homeopathic medicines. It claimed that CVS was selling homeopathic products on an easier-to-obtain basis than standard medication. In 2019, CFI brought a similar lawsuit against Walmart for "committing wide-scale consumer fraud and endangering the health of its customers through its sale and marketing of homeopathic medicines". They also conducted a survey in which they found consumers felt ripped off when informed of the lack of evidence for the efficacy of homeopathic remedies, such as those sold by Walmart and CVS. In 2021, the French healthcare minister phased out social security reimbursements for homeopathic drugs. Spain has also announced moves to ban homeopathy and other pseudotherapies. Shortly afterwards the University of Valencia announced the elimination of its Masters in Homeopathy.

Preparations and treatment Homeopathic preparations are referred to as "homeopathic remedies". Practitioners rely on two types of reference when prescribing: Materia medica and repertories. A homeopathic materia medica is a collection of "drug pictures", organized alphabetically. A homeopathic repertory is a quick reference version of the materia medica that indexes the symptoms and then the associated remedies for each. In both cases different compilers may dispute particular inclusions in the references. The first symptomatic homeopathic materia medica was arranged by Hahnemann. The first homeopathic repertory was Georg Jahr's Symptomenkodex, published in German in 1835, and translated into English as the Repertory to the more Characteristic Symptoms of Materia Medica in 1838. This version was less focused on disease categories and was the forerunner to later works by James Tyler Kent. There are over 118 repertories published in English, with Kent's being one of the most used.

Consultation Homeopaths generally begin with a consultation, which can be a 10-15 minute appointment or last for over an hour, where the patient describes their medical history. The patient describes the "modalities", or if their symptoms change depending on the weather and other external factors. The practitioner also solicits information on mood, likes and dislikes, physical, mental and emotional states, life circumstances, and any physical or emotional illnesses. This information is matched to the "drug picture" in the materia medica or repertory and used to determine the appropriate homeopathic remedies. In classical homeopathy, the practitioner attempts to match a single preparation to the totality of symptoms, while "clinical homeopathy" involves combinations of preparations based on the illness's symptoms.

Examples include arsenicum album, natrum muriaticum, Lachesis muta, opium, and thyroidinum . Homeopaths say this is to ensure accuracy. In the USA the common name must be displayed, although the Latin one can also be present.

Isopathy is a therapy derived from homeopathy where the preparations come from diseased or pathological products such as fecal, urinary, respiratory discharges, blood, and tissue. Tautopathy is a form of isopathy where the preparations are composed of drugs or vaccines that a person has consumed in the past, in the belief that this can reverse the supposed lingering damage caused by the initial use. There is no convincing scientific evidence for isopathy as an effective method of treatment.

Some modern homeopaths use preparations they call "imponderables" because they do not originate from a substance but some other phenomenon presumed to have been "captured" by alcohol or lactose. Examples include X-rays and sunlight. Another derivative is electrohomoeopathy, where an electric bio-energy of therapeutic value is supposedly extracted from plants. Popular in the late nineteenth century, electrohomeopathy is extremely pseudo-scientific. In 2012, the Allahabad High Court in Uttar Pradesh, India, handed down a decree stating that electrohomeopathy was quackery and no longer recognized it as a system of medicine .

Other minority practices include paper preparations, where the substance and dilution are written on pieces of paper and either pinned to the patients' clothing, put in their pockets, or placed under glasses of water that are then given to the patients. Radionics, the use of electromagnetic radiation such as radio waves, can also be used to manufacture preparations. Such practices have been strongly criticized by classical homeopaths as unfounded, speculative, and verging upon magic and superstition. Flower preparations are produced by placing flowers in water and exposing them to sunlight. The most famous of these are the Bach flower remedies, which were developed by Edward Bach.

Dilutions Hahnemann claimed that undiluted doses caused reactions, sometimes dangerous ones, and thus that preparations be given at the lowest possible dose. A solution that is more dilute is described as having a higher "potency", and thus are claimed to be stronger and deeper-acting. The general method of dilution is serial dilution, where solvent is added to

part of the previous mixture, but the "Korsakov Ian" method may also be used. In the Korsakov Ian method, the vessel in which the preparations are manufactured is emptied, refilled with solvent, with the volume of fluid adhering to the walls of the vessel deemed sufficient for the new batch. Another method is Fluxion, which dilutes the substance by continuously passing water through the vial. Insoluble solids, such as granite, diamond, and platinum, are diluted by grinding them with lactose . The centesimal scale was favoured by Hahnemann for most of his life, although in his last ten years Hahnemann developed a quintamillesimal scale which diluted the drug 1 part in 50,000. A 2C dilution works out to one part of the original substance in 10,000 parts of the solution. In standard chemistry, this produces a substance with a concentration of 0.01% . A 6C dilution ends up with the original substance diluted by a factor of 100−6 .

The end product is usually so diluted as to be indistinguishable from the diluent . The greatest dilution reasonably likely to contain at least one molecule of the original substance is approximately 12C. Hahnemann advocated dilutions of 1 part to 1060 or 30C. Hahnemann regularly used dilutions of up to 300C but opined that "there must be a limit to the matter". One mathematically correct example is that a 12C solution is equivalent to "a pinch of salt in both the North and South Atlantic Oceans". One-third of a drop of some original substance diluted into all the water on earth would produce a preparation with a concentration of about 13C. A 200C dilution of duck liver, marketed under the name Oscillococcinum, would require 10320 universes worth of molecules to contain just one original molecule in the final substance. The high dilutions characteristically used are often considered to be the most controversial and implausible aspect of homeopathy.

Provings Homeopaths claim that they can determine the properties of their preparations by following a method which they call "proving". As performed by Hahnemann, provings involved administering various preparations to healthy volunteers.

The volunteers were then observed, often for months at a time. They were made to keep extensive journals detailing all of their symptoms at specific times throughout the day. They were forbidden from consuming coffee, tea, spices, or wine for the duration of the experiment; playing chess was also prohibited because Hahnemann considered it to be "too exciting", though they were allowed to drink beer and encouraged to exercise in moderation. At first Hahnemann used undiluted doses for provings, but he later advocated provings with preparations at a 30C dilution, Provings are claimed to have been important in the development of the clinical trial, due to their early use of simple control groups, systematic and quantitative procedures, and some of the first application of statistics in medicine. The lengthy records of self-experimentation by homeopaths have occasionally proven useful in the development of modern drugs: For example, evidence that nitroglycerin might be useful as a treatment for angina was discovered by looking through homeopathic provings, though homeopaths themselves never used it for that purpose at that time. The first recorded provings were published by Hahnemann in his 1796 Essay on a New Principle. His Fragmenta de Viribus contained the results of 27 provings, and his 1810 Materia Medica Pura contained 65. For James Tyler Kent's 1905 Lectures on Homoeopathic Materia Medica, 217 preparations underwent provings and newer substances are continually added to contemporary versions.

Though the proving process has superficial similarities with clinical trials, it is fundamentally different in that the process is subjective, not blinded, and modern provings are unlikely to use pharmacologically active levels of the substance under proving. As early as 1842, Oliver Holmes had noted that provings were impossibly vague, and the purported effect was not repeatable among different subjects. or a pseudoscience and the medical community regards it as quackery. and its use of preparations without active ingredients have led to characterizations of homeopathy as pseudoscience and quackery, or, in the words of a 1998 medical review, "placebo therapy at best and quackery at worst". The Russian Academy of Sciences considers homeopathy a "dangerous 'pseudoscience' that does not work", and "urges people to treat homeopathy 'on a par with magic. In 2013, Mark Walport, the UK Government Chief Scientific Adviser and head of the Government Office for Science said "homeopathy is nonsense, it is non-science." His predecessor, John Beddington,

also said that homeopathy "has no underpinning of scientific basis" and is being "fundamentally ignored" by the Government.

Jack Killen, acting deputy director of the National Center for Complementary and Alternative Medicine, says homeopathy "goes beyond current understanding of chemistry and physics". He adds: "There is, to my knowledge, no condition for which homeopathy has been proven to be an effective treatment." Homeopaths often prefer to ignore meta-analyses in favour of cherry picked positive results, such as by promoting a particular observational study as if it were more informative than a series of randomized controlled trials. published in the American Journal of Medicine, Michael Baum and Edzard Ernstwriting to other physicianswrote that "Homeopathy is among the worst examples of faith-based medicine... These axioms are not only out of line with scientific facts but also directly opposed to them. If homeopathy is correct, much of physics, chemistry, and pharmacology must be incorrect...".

Plausibility of dilutions The exceedingly low concentration of homeopathic preparations, which often lack even a single molecule of the diluted substance, has been the basis of questions about the effects of the preparations since the 19th century. James Randi and the 10:23 campaign groups have highlighted the lack of active ingredients by taking large 'overdoses'. None of the hundreds of demonstrators in the UK, Australia, New Zealand, Canada and the US were injured and "no one was cured of anything, either". Existence of a pharmacological effect in the absence of any true active ingredient is inconsistent with the law of mass action and the observed dose-response relationships characteristic of therapeutic drugs.

Homeopaths contend that their methods produce a therapeutically active preparation, selectively including only the intended substance, though critics note that any water will have been in contact with millions of different substances throughout its history, and homeopaths have not been able to account for a reason why only the selected homeopathic substance would be a special case in their process. but the dose-response relationship outside the zone of hormesis declines with dilution as normal, and nonlinear pharmacological effects do not provide any credible support for homeopathy.

Efficacy No individual homeopathic preparation has been unambiguously shown by research to be different from placebo. A review conducted in 2010 of all the pertinent studies of "best evidence" produced by the Cochrane Collaboration concluded that "the most reliable evidence – that produced by Cochrane reviews – fails to demonstrate that homeopathic medicines have effects beyond placebo." The European Academies' Science Advisory Council published its official analysis in 2017 finding a lack of evidence that homeopathic products are effective, and raising concerns about quality control. Although hailed by proponents as proof that homeopathy works, it was found to be scientifically, logically and ethically flawed, with most authors having a conflict of interest.

Meta-analyses, essential tools to summarize evidence of therapeutic efficacy, and systematic reviews have found that the methodological quality in the majority of randomized trials in homeopathy have shortcomings and that such trials were generally of lower quality than trials of conventional medicine. A major issue has been publication bias, where positive results are more likely to be published in journals. This has been particularly marked in alternative medicine journals, where few of the published articles tend to report null results.

Health organizations, including the UK's National Health Service, the American Medical Association, the FASEB, and the National Health and Medical Research Council of Australia, They warned against the use of homeopathy for serious conditions such as depression, HIV and malaria. The American College of Medical Toxicology and the American Academy of Clinical Toxicology recommend that no one use homeopathic treatment for disease or as a preventive health measure. These organizations report that no evidence exists that homeopathic treatment is effective, but that there is evidence that using these treatments produces harm and can bring indirect health risks by delaying conventional

treatment. and enzyme reactions, such evidence is disputed since attempts to replicate them have failed. In 2001 and 2004, Madeleine Ennis published a number of studies that reported that homeopathic dilutions of histamine exerted an effect on the activity of basophils. In response to the first of these studies, Horizon aired a programme in which British scientists attempted to replicate Ennis' results; they were unable to do so. A 2007 systematic review of high-dilution experiments found that none of the experiments with positive results could be reproduced by all investigators.

In 1988, French immunologist Jacques Benveniste published a paper in the journal Nature while working at INSERM. The paper purported to have discovered that basophils, released histamine when exposed to a homeopathic dilution of antiimmunoglobulin E antibody. Sceptical of the findings, Nature assembled an independent investigative team to determine the accuracy of the research After investigation the team found that the experiments were "statistically illcontrolled", "interpretation has been clouded by the exclusion of measurements in conflict with the claim", and concluded, "We believe that experimental data have been uncritically assessed and their imperfections inadequately reported."

Ethics and safety The provision of homeopathic preparations has been described as unethical. Michael Baum, Professor Emeritus of Surgery and visiting Professor of Medical Humanities at University College London, has described homeopathy as a "cruel deception". Edzard Ernst, the first Professor of Complementary Medicine in the United Kingdom and a former homeopathic practitioner, has expressed his concerns about pharmacists who violate their ethical code by failing to provide customers with "necessary and relevant information" about the true nature of the homeopathic products they advertise and sell. In 2013 the UK Advertising Standards Authority concluded that the Society of Homeopaths were targeting vulnerable ill people and discouraging the use of essential medical treatment while making misleading claims of efficacy for homeopathic products. In 2015 the Federal Court of Australia imposed penalties on a homeopathic company for making false or misleading statements about the efficacy of the whooping cough vaccine and recommending homeopathic remedies as an alternative.A 2000 review by homeopaths reported that homeopathic preparations are "unlikely to provoke severe adverse reactions". In 2012, a systematic review evaluating evidence of homeopathy's possible adverse effects concluded that "homeopathy has the potential to harm patients and consumers in both direct and indirect ways". A 2016 systematic review and meta-analysis found that, in homeopathic clinical trials, adverse effects were reported among the patients who received homeopathy about as often as they were reported among patients who received placebo or conventional medicine.

Some homeopathic preparations involve poisons such as Belladonna, arsenic, and poison ivy. In rare cases, the original ingredients are present at detectable levels. This may be due to improper preparation or intentional low dilution.

Serious adverse effects such as seizures and death have been reported or associated with some homeopathic preparations. In 2016 the FDA issued a safety alert to consumers warning against the use of homeopathic teething gels and tablets following reports of adverse events after their use. A previous FDA investigation had found that these products were improperly diluted and contained "unsafe levels of belladonna" and that the reports of serious adverse events in children using this product were "consistent with belladonna toxicity".

Patients who choose to use homeopathy rather than evidence-based medicine risk missing timely diagnosis and effective treatment, thereby worsening the outcomes of serious conditions such as cancer. Critics have cited cases of patients failing to receive proper treatment for diseases that could have been easily managed with conventional medicine and who have died as a result. They have also condemned the "marketing practice" of criticizing and downplaying the effectiveness of medicine. In 1978, Anthony Campbell, a consultant physician at the Royal London Homeopathic Hospital, criticized statements by George Vithoulkas claiming that syphilis, when treated with antibiotics, would develop into secondary and tertiary syphilis with involvement of the central nervous system. Vithoulkas' claims echo the idea that treating a disease with external medication used to treat the symptoms would only drive it deeper

into the body and conflict with scientific studies, which indicate that penicillin treatment produces a complete cure of syphilis in more than 90% of cases.

The use of homeopathy as a preventive for serious infectious diseases, called homeoprophylaxis, is especially controversial. Some homeopaths advise their patients against immunization. Others have suggested that vaccines be replaced with homeopathic "nosodes". While Hahnemann was opposed to such preparations, modern homeopaths often use them although there is no evidence to indicate they have any beneficial effects. Promotion of homeopathic alternatives to vaccines has been characterized as dangerous, inappropriate and irresponsible. In December 2014, the Australian homeopathy supplier Homeopathy Plus! was found to have acted deceptively in promoting homeopathic alternatives to vaccines. In 2019, an investigative journalism piece by the Telegraph revealed that homeopathy practitioners were actively discouraging patients from vaccinating their children. Cases of homeopaths advising against the use of anti-malarial drugs have also been identified.

A 2006 review recommends that pharmacy colleges include a required course where ethical dilemmas inherent in recommending products lacking proven safety and efficacy data be discussed and that students should be taught where unproven systems such as homeopathy depart from evidence-based medicine.

Regulation and prevalence Homeopathy is fairly common in some countries while being uncommon in others; is highly regulated in some countries and mostly unregulated in others. It is practiced worldwide and professional qualifications and licences are needed in most countries. A 2019 WHO report found that 100 out of 133 Member States surveyed in 2012 acknowledged that their population used homeopathy, with 22 saying the practice was regulated and 13 providing health insurance coverage. In some countries, there are no specific legal regulations concerning the use of homeopathy, while in others, licences or degrees in conventional medicine from accredited universities are required. In 2001 homeopathy had been integrated into the national health care systems of many countries, including India, Mexico, Pakistan, Sri Lanka, and the United Kingdom. And Luxembourg. It used to be covered in France until 2021. but exceptions can be made; private health insurance policies sometimes include homeopathic treatments. The Swiss government withdrew coverage of homeopathy and four other complementary treatments in 2005, stating that they did not meet efficacy and costeffectiveness criteria, but following a referendum in 2009 the five therapies were reinstated for a further 6-year trial period. In Germany, homeopathic treatments are covered by 70 percent of government medical plans, and available in almost every pharmacy. In 2016 the UK's Committee of Advertising Practice compliance team wrote to homeopaths in the UK to "remind them of the rules that govern what they can and can't say in their marketing materials". The letter told homeopaths to "ensure that they do not make any direct or implied claims that homeopathy can treat medical conditions" and asks them to review their marketing communications "including websites and social media pages" to ensure compliance. Homeopathic services offered at Bristol Homeopathic Hospital in the UK ceased in October 2015, Member states or the European Union are required to ensure that homeopathic products are registered, although this process does not require any proof of efficacy. In Spain the Association for the protection of patients from pseudoscientific therapies is lobbying to get rid of the easy registration procedure for homeopathic remedies.

The Indian government recognizes homeopathy as one of its national systems of medicine and they are sold with medical claims. The south Indian state of Kerala also has a cabinet-level AYUSH department. The Central Council of Homoeopathy was established in 1973 to monitor higher education in homeopathy, and the National Institute of Homoeopathy in 1975. Principals and standards for homeopathic products are covered by the Homoeopathic pharmacopoeia of India.

Some medical schools in Pakistan, India, and Bangladesh, offer an undergraduate degree programme in homeopathy.

Upon completion the college may award a '' .

In the United States each state is responsible for the laws and licensing requirements for homeopathy. In 2015, the FDA held a hearing on homeopathic product regulation. Representatives from the Center for Inquiry and the Committee for Skeptical Inquiry gave a testimonial which summarized the harm that is done to the general public from homeopathics and proposed regulatory actions: In 2016 the United States Federal Trade Commission issued an "Enforcement Policy Statement Regarding Marketing Claims for Over-the-Counter Homeopathic Drugs" which specified that the FTC will apply the same standard to homeopathic drugs that it applies to other products claiming similar benefits. A related report concluded that claims of homeopathy effectiveness "are not accepted by most modern medical experts and do not constitute competent and reliable scientific evidence that these products have the claimed treatment effects." In 2019 the FDA removed an enforcement policy that permitted unapproved homeopathics to be sold. Currently no homeopathic products are approved by the FDA. Homeopathic remedies are regulated as natural health products for in Canada. Health Canada requires all products to have a licence before being sold and applicants have to submit evidence on "the safety, efficacy and quality of a homeopathic medicine". In 2015 the Canadian Broadcasting Corporation tested the system by applying for and then receiving a government approved licence for a made-up drug aimed at kids.

In Australia, the sale of homeopathic products is regulated by the Therapeutic Goods Administration. In 2015, the National Health and Medical Research Council of Australia concluded that there is "no reliable evidence that homeopathy is effective and should not be used to treat health conditions that are chronic, serious, or could become serious". They recommended anyone considering using homeopathy should first get advice from a registered health practitioner. while noting the concerns the government did not adopt the recommendation. In New Zealand there are no regulations specific to homeopathy and the New Zealand Medical Association does not oppose the use of homeopathy, a stance that has been called unethical by some doctors.

Prevalence Homeopathy is one of the most commonly used forms of alternative medicines and it has a large worldwide market.

Major retailers like Walmart, CVS, and Walgreens sell homeopathic products that are packaged to resemble conventional medicines. With 2.9 billion spent in 2007. Homeopathy is used in China, although it arrived a lot later than in many other countries, partly due to the restriction on foreigners that persisted until late in the nineteenth century.

Throughout Africa there is a high reliance on traditional medicines, which can be attributed to the cost of modern medicines and the relative prevalence of practitioners. Many African countries do not have any official training facilities.

The use of homeopathy in the organic farming industry is heavily promoted. Given that homeopathy's effects in humans are due to the placebo effect and the counseling aspects of the consultation, such treatments are even less effective in animals. Studies have also found that giving animals placebos can play active roles in influencing pet owners to believe in the effectiveness of the treatment when none exists.

Little existing research on the subject is of a high enough scientific standard to provide reliable data on efficacy. A 2016 review of peer-reviewed articles from 1981 to 2014 by scientists from the University of Kassel, Germany, concluded that there is not enough evidence to support homeopathy as an effective treatment of infectious diseases in livestock. The UK's Department for Environment, Food and Rural Affairs has adopted a robust position against use of "alternative" pet preparations including homeopathy. The British Veterinary Association's position statement on alternative medicines says that it "cannot endorse" homeopathy, and the Australian Veterinary Association includes it on its list of "ineffective therapies".

NaturopathyNaturopathy or naturopathic medicine is a form of alternative medicine that employs an array of pseudoscientific practices branded as "natural", "non-invasive", or promoting "self-healing". The ideology and methods of naturopathy are based on vitalism and folk medicine, rather than evidence-based medicine . Instead, naturopathic practice relies on unscientific notions, often leading naturopaths to diagnoses and treatments that have no factual merit.

Naturopathy is considered by the medical profession to be ineffective and harmful, raising ethical issues about its practice. naturopaths have repeatedly been denounced as and accused of being charlatans and practicing quackery.

Naturopaths are known for their frequent campaigning for legal recognition in the United States. Naturopathy has its roots in the 19th-century Natural Cure movement of Europe. In Scotland, Thomas Allinson started advocating his "Hygienic Medicine" in the 1880s, promoting a natural diet and exercise with avoidance of tobacco and overwork.

The term naturopathy was coined in 1895 by John Scheel, Lust had been schooled in hydrotherapy and other natural health practices in Germany by Father Sebastian Kneipp; Kneipp sent Lust to the United States to spread his drugless methods. Lust defined naturopathy as a broad discipline rather than a particular method, and included such techniques as hydrotherapy, herbal medicine, and homeopathy, as well as eliminating overeating, tea, coffee, and alcohol. He described the body in spiritual and vitalistic terms with "absolute reliance upon the cosmic forces of man's nature".

According to the Merriam-Webster Dictionary, the first known use of "naturopathy" in print is from 1901.

From 1901, Lust founded the American School of Naturopathy in New York. In 1902, the original North American Kneipp Societies were discontinued and renamed "Naturopathic Societies". In September 1919, the Naturopathic Society of America was dissolved and Benedict Lust founded the American Naturopathic Association to supplant it. Naturopaths became licensed under naturopathic or drugless practitioner laws in 25 states in the first three decades of the twentieth century. In 1977 an Australian committee of inquiry reached similar conclusions; it did not recommend licensure for naturopaths.

Beginning in the 1970s, there was a revival of interest in the United States and Canada, in conjunction with the "holistic health" movement. and the State of Washington requires insurance companies to offer reimbursement for services provided by naturopathic physicians. On the other hand, some states such as South Carolina and Tennessee prohibit the practice of naturopathy.

Practice The practice of naturopathy is based on a belief in the body's ability to heal itself through a special vital energy or force guiding bodily processes internally. Naturopaths focus on a holistic approach, completely avoiding the use of surgery and conventional medicines. Naturopaths aim to prevent illness through stress reduction and changes to diet and lifestyle, often rejecting the methods of evidence-based medicine.

A consultation typically begins with a lengthy patient interview focusing on lifestyle, medical history, emotional tone, and physical features, as well as physical examination. Traditional naturopaths deal exclusively with lifestyle changes, not diagnosing or treating disease. Naturopaths do not generally recommend vaccines and antibiotics, based in part on the early views that shaped the profession, and they may provide alternative remedies even in cases where evidencebased medicine has been shown effective.

The particular modalities used by a naturopath vary with training and scope of practice. These may include herbalism, homeopathy, chelation therapy, color therapy, cranial osteopathy, hair analysis, iridology, Physical medicine includes naturopathic, osseous, or soft tissue manipulative therapy, sports medicine, exercise, and hydrotherapy. Psychological counseling includes meditation, relaxation, and other methods of stress management. An examination published in 2011 of naturopathic clinic websites in Alberta and British Columbia found that the most commonly advertised therapies were homeopathy, botanical medicine, nutrition, acupuncture, lifestyle counseling, and detoxification.

Evidence basis Naturopathy as a whole lacks an adequate scientific basis, and it is rejected by the medical community. Naturopathy is criticized for its reliance on and its association with unproven, disproven, and other controversial alternative medical treatments, and for its vitalistic underpinnings. According to the American Cancer Society, "scientific evidence does not support claims that naturopathic medicine can cure cancer or any other disease".

In 2015, the Australian Government's Department of Health published the results of a review of alternative therapies that sought to determine if any were suitable for being covered by health insurance; Naturopathy was one of 17 therapies evaluated for which no clear evidence of effectiveness was found.

Kimball C. Atwood IV writes, in the journal Medscape General Medicine, and that while some naturopaths claim to only practice evidence based medicine, "the problem is, all naturopaths in an accredited naturopathic program are required to extensively study homeopathy, herbal medicine, energy healing, chiropractic techniques, water therapy" and other pseudoscientific practices.

According to Arnold S. Relman, the Textbook of Natural Medicine is inadequate as a teaching tool, as it omits to mention or treat in detail many common ailments, improperly emphasizes treatments "not likely to be effective" over those that are, and promotes unproven herbal remedies at the expense of pharmaceuticals. He concludes that "the risks to many sick patients seeking care from the average naturopathic practitioner would far outweigh any possible benefits".

The Massachusetts Medical Society states, "Naturopathic practices are unchanged by research and remain a large assortment of erroneous and potentially dangerous claims mixed with a sprinkling of non-controversial dietary and lifestyle advice."

Certain naturopathic treatments offered by naturopaths, such as homeopathy, rolfing, and iridology, are widely considered pseudoscience or quackery. Stephen Barrett of QuackWatch and the National Council Against Health Fraud has stated that naturopathy is "simplistic and that its practices are riddled with quackery". "Non-scientific health care practitioners, including naturopaths, use unscientific methods and deception on a public who, lacking in-depth health care knowledge, must rely upon the assurance of providers. Quackery not only harms people, it undermines the ability to conduct scientific research and should be opposed by scientists", says William T. Jarvis. In the 2018 Australian case against Marlyin Bodnar, who advised a mother to treat her infant son's eczema with a raw food diet which nearly led to the child's starvation death, Judge Peter Berman said, "Well-intentioned but seriously misguided advice is, as the facts of this case demonstrate, capable of causing great harm and even death to vulnerable children." Furthermore, Britt Hermes criticizes the "pervasive culture of patient blaming" among naturopathic practitioners, where "when something doesn’t work for the patient and the patient is not experiencing all of the positive effects and zero side-effects that are promised with the therapy, it’s never because the therapy doesn’t work, it’s because the patient didn’t do something right." A naturopathy textbook, co-authored by Joseph Pizzorno, recalls anti-vaccine beliefs associated with the founding of naturopathy in the United States: "a return to nature in regulating the diet, breathing, exercising, bathing and the employment of various forces" in lieu of the smallpox vaccine.

In general, evidence about associations between naturopathy and pediatric vaccination is sparse, but "published reports suggest that only a minority of naturopathic physicians actively support full vaccination". In Washington state from 2000 to 2003, children were significantly less likely to receive immunizations if they had seen a naturopath. and the group's policy is to not advocate for or against vaccines. The Oregon Association of Naturopathic Physicians reports that many naturopaths "customize" the pediatric vaccine schedule. , the American Association of Naturopathic Physicians, which is the largest professional organization for licensed naturopaths in the U.S., is "still discussing its stance on vaccinations."

Practitioners Naturopath practitioners can generally be categorized into three groups: 1) those with a government issued license; 2) those who practice outside of an official status ; 3) those who are primarily another kind of health professional who also practices naturopathy.

In Switzerland, these divisions fall between those with a federal diploma, those recognized by health insurances, and those with neither federal diploma nor recognition by health insurances. Naturopaths with federal diploma can be divided into four categories: European traditional medicine, Chinese traditional medicine, ayurvedic medicine and homeopathy. The number of listed naturopaths in Switzerland rose from 223 in 1970 to 1835 in 2000.

Licensed naturopaths Licensed naturopaths may be referred to as "naturopathic doctors" or "naturopathic physicians" in 17 US states and 5 Canadian provinces. Licensed naturopaths present themselves as primary care providers. However, section 102 of the bylaw of the College of Naturopathic Physicians of British Columbia, the terms "naturopathic" or "naturopathic medicine" must be included anytime the term doctor or physician is used by a member of the CNPBC. Education Licensed naturopaths must pass the Naturopathic Physicians Licensing Examinations administered by the North American Board of Naturopathic Examiners after graduating from a program accredited by the Council on Naturopathic Medical Education . Training in CNME-accredited programs includes basic medical diagnostics and procedures such as rudimentary physical exams and common blood tests, in addition to pseudoscientific modalities, such as homeopathy, acupuncture, and energy modalities. The CNME as an accrediting authority has been characterized as unreliable and suffering from conflicts of interest. The naturopathic licensing exam has been called a mystery by those outside the naturopathic profession and criticized for testing on homeopathic remedies, including for the use to treat pediatric emergencies. Most naturopathic doctors do not complete such a residency, Continuing education in naturopathic modalities for health care professionals varies greatly. Naturopathic lobbying efforts are funded by vitamin and supplement makers Medical societies and advocacy groups dispute these claims by citing evidence of licensed naturopaths using pseudoscientific methods without a sound evidence basis and lacking adequate clinical training to diagnose and treat disease competently according to the standard of care. Jann Bellamy has characterized the process by which naturopaths and other practitioners of pseudoscience convince lawmakers to provide them with medical licenses as "legislative alchemy".

Since 2005, the Massachusetts Medical Society has opposed licensure based on concerns that NDs are not required to participate in residency and concerns that the "practices" of naturopaths included many "erroneous and potentially dangerous claims." The Massachusetts Special Commission on Complementary and Alternative Medical Practitioners rejected their concerns and recommended licensure. The Massachusetts Medical Society states: In addition to opposing further licensure, she believes that NDs should not be allowed to use the titles "doctor" or "physician", She states:

Traditional naturopaths Traditional naturopaths are represented in the United States by the American Naturopathic Association, representing about 1,800 practitioners and the American Naturopathic Medical Association . but this claim remains inaccurate.

In 2015, the Australian government found no clear evidence of effectiveness for naturopathy.

India In India, naturopathy is overseen by the Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy ; there is a 5½-year degree in "Bachelor of Naturopathy and Yogic Sciences" degree that was offered by twelve colleges in India . The National Institute of Naturopathy in Pune that operates under AYUSH, which was established on December 22, 1986 and encourages facilities for standardization and propagation of the existing knowledge and its application through research in naturopathy throughout India.

North America In five Canadian provinces, seventeen U.S. states, and the District of Columbia, naturopathic doctors who are trained at an accredited school of naturopathic medicine in North America are entitled to use the designation ND or NMD. Elsewhere, the designations "naturopath", "naturopathic doctor", and "doctor of natural medicine" are generally unprotected or prohibited.

Canada Five Canadian provinces license naturopathic doctors: Ontario, British Columbia, Manitoba, Saskatchewan, and Alberta.

British Columbia has the largest scope of practice in Canada, allowing certified NDs to prescribe pharmaceuticals and perform minor surgeries.

United States U.S. jurisdictions that currently regulate or license naturopathy include Alaska, Arizona, California, Connecticut, Colorado, District of Columbia, Hawaii, Kansas, Maine, Maryland, Minnesota, Montana, New Hampshire, North Dakota, Oregon, Puerto Rico, US Virgin Islands, Utah, Vermont, and Washington. In particular, the Federal authorities must set up diplomas for the practice of non-scientific medicine. The first of such diplomas has been validated in April 2015 for the practice of naturopathy.

OphthalmologistOphthalmology is a branch of medicine and surgery that deals with the diagnosis and treatment of disorders of the eye.

An ophthalmologist is a physician who specializes in ophthalmology. The credentials include a degree in medicine, followed by additional four to five years of residency training in ophthalmology. Residency training programs for ophthalmology may require a one-year internship with training in internal medicine, pediatrics, or general surgery.

Additional specialty training may be sought in a particular aspect of eye pathology. Ophthalmologists are allowed to prescribe medications to treat eye diseases, implement laser therapy, and perform surgery when needed.

Ophthalmologists may participate in academic research on the diagnosis and treatment for eye disorders.

Diseases A partial list of the most common diseases treated by ophthalmologists include: Cataract Excessive tearing Proptosis Eye tumors Diabetic retinopathy Dry eye syndrome Glaucoma Macular degeneration Refractive errors Strabismus Uveitis Diagnosis Eye examination Following are examples of examination methods performed during an eye examination that enables diagnosis Ocular tonometry to determine intraocular pressure Refraction assessment Retina examination Slit lamp examination Visual acuity Specialized tests

Optical coherence tomography is a medical technological platform used to assess ocular structures. The information is then used by physicians to assess staging of pathological processes and confirm clinical diagnoses. Subsequent OCT scans are used to assess the efficacy of managing diabetic retinopathy, age-related macular degeneration, and glaucoma.

Ultrasonography of the eyes may be performed by an opthalmologist.

Ophthalmic surgery Eye surgery, also known as ocular surgery, is surgery performed on the eye or its adnexa by an ophthalmologist. The eye is a fragile organ, and requires extreme care before, during, and after a surgical procedure. An eye surgeon is responsible for selecting the appropriate surgical procedure for the patient and for taking the necessary safety precautions.

Subspecialties Ophthalmology includes subspecialities that deal either with certain diseases or diseases of certain parts of the eye.

Some of them are: Anterior segment surgery Cornea, ocular surface, and external disease Glaucoma Neuro-ophthalmology Ocular oncology Oculoplastics and orbit surgery Ophthalmic pathology Paediatric ophthalmology/strabismus Refractive surgery Medical retina, deals with treatment of retinal problems through non-surgical means Uveitis Veterinary specialty training programs in veterinary ophthalmology exist in some countries.

Vitreo-retinal surgery, deals with surgical management of retinal and posterior segment diseases Medical retina and vitreo-retinal surgery sometimes are combined and together they are called posterior segment subspecialisation Etymology The Greek roots of the word ophthalmology are ὀφθαλμόσ and -λoγία, i.e., "the study of eyes". The discipline applies to all animal eyes, whether human or not, since the practice and procedures are quite similar with respect to disease processes, while differences in anatomy or disease prevalence, whether subtle or substantial, may differentiate the two.

History Ancient near east and the Greek period In the Ebers Papyrus from ancient Egypt dating to 1550 BC, a section is devoted to eye diseases. which describes 76 ocular diseases as well as several ophthalmological surgical instruments and techniques. His description of cataract surgery was compatible with the method of couching. He has been described as one of the first cataract surgeons.

Medieval Islam Medieval Islamic Arabic and Persian scientists considered it normal to combine theory and practice, including the crafting of precise instruments, and therefore, found it natural to combine the study of the eye with the practical application of that knowledge. Hunayn ibn Ishaq, and others beginning with the medieval Arabic period, taught that the crystalline lens is in the exact center of the eye. This idea was propagated until the end of the 1500s.

Avicenna wrote in his Canon "rescheth", which means "retiformis", and Gerard of Cremona translated this at approximatelt 1150 into the new term "retina".

Modern Period In the seventeenth and eighteenth centuries, hand lenses were used by Malpighi, microscopes by Leeuwenhoek, preparations for fixing the eye for study by Ruysch, and later the freezing of the eye by Petit. This allowed for detailed study of the eye and an advanced model. Some mistakes persisted, such as: why the pupil changed size, the existence of the posterior chamber, and the nature of the retina. Unaware of their functions, Leeuwenhoek noted the existence of photoreceptors, however, they were not properly described until Gottfried Reinhold Treviranus in 1834.

Approximately 1750, Jacques Daviel advocated a new treatment for cataract by extraction instead of the traditional method of couching.

In North America, indigenous healers treated some eye diseases by rubbing or scraping the eyes or eyelids.

Ophthalmic surgery in Great Britain The first ophthalmic surgeon in Great Britain was John Freke, appointed to the position by the governors of St. Bartholomew's Hospital in 1727. A major breakthrough came with the appointment of Baron de Wenzel, a German who became the oculist to King George III of Great Britain in 1772. His skill at removing cataracts legitimized the field. The first dedicated ophthalmic hospital opened in 1805 in London; it is now called Moorfields Eye Hospital. Clinical developments at Moorfields and the founding of the Institute of Ophthalmology by Sir Stewart Duke-Elder established the site as the largest eye hospital in the world and a nexus for ophthalmic research.

Central Europe In Berlin, ophthalmologist Albrecht von Graefe introduced iridectomy as a treatment for glaucoma and improved cataract surgery, he is also considered the founding father of the German Ophthalmological Society.

Numerous ophthalmologists fled Germany after 1933 as the Nazis began to persecute those of Jewish descent. A representative leader was Joseph Igersheimer, best known for his discoveries with arsphenamine for the treatment of syphilis. He fled to Turkey in 1933. As one of eight emigrant directors in the Faculty of Medicine at the University of Istanbul, he built a modern clinic and trained students. In 1939, he went to the United States, becoming a professor at Tufts University. German ophthalmologist, Gerhard Meyer-Schwickerath is widely credited with developing the predecessor of laser coagulation, photocoagulation.

In 1946, Igersheimer conducted the first experiments on light coagulation. In 1949, he performed the first successful treatment of a retinal detachment with a light beam with a self-constructed device on the roof of the ophthalmic clinic at the University of Hamburg-Eppendorf.

Polish ophthalmology dates to the thirteeth century. The Polish Ophthalmological Society was founded in 1911. A representative leader was Adam Zamenhof, who introduced certain diagnostic, surgical, and nonsurgical eye-care procedures. He was executed by the German Nazis in 1940.

Zofia Falkowska head of the Faculty and Clinic of Ophthalmology in Warsaw from 1963 to 1976, was the first to use lasers in her practice.

Advances by opticians The prominent opticians of the late nineteenth and early twentieth centuries included Ernst Abbe, a co-owner of at the Zeiss Jena factories in Germany, where he developed numerous optical instruments. Hermann von Helmholtz was a polymath who made contributions to many fields of science and invented the ophthalmoscope in 1851. They both made theoretical calculations on image formation in optical systems and also had studied the optics of the eye.

Professional requirements Ophthalmologists are physicians who have completed a college degree, medical school, and residency in ophthalmology.

Training in ophthalmology equips eye specialists to provide the full spectrum of eye care, including the prescription of glasses and contact lenses, medical treatment, and complex microsurgery. In many countries, ophthalmologists also undergo additional specialized training in one of the many subspecialties. Ophthalmology was the first branch of medicine to offer board certification, now a standard practice among all specialties.

Australia and New Zealand In Australia and New Zealand, the FRACO or FRANZCO is the equivalent postgraduate specialist qualification. The structured training system takes place over five years of postgraduate training. Overseas-trained ophthalmologists are assessed using the pathway published on the RANZCO website. Those who have completed their formal training in the UK and have the CCST or CCT, usually are deemed to be comparable.

Bangladesh In Bangladesh to be an ophthalmologist the basic degree is an MBBS. Then they have to obtain a postgraduate degree or diploma in an ophthalmology specialty. In Bangladesh, these are diploma in ophthalmology, diploma in community ophthalmology, fellow or member of the College of Physicians and Surgeons in ophthalmology, and master of science in ophthalmology.

Canada In Canada, after medical school and ophthalmology residency is undertaken. The residency lasts a minimum of five years after the M.D. degree, which culminates in fellowship of the Royal College of Surgeons of Canada. Subspecialty training is undertaken by approximately 30% of fellows in a variety of fields from anterior segment, cornea, glaucoma, vision rehabilitation, uveitis, oculoplastics, medical and surgical retina, ocular oncology, Ocular pathology, or neuroophthalmology. Approximately 35 vacancies open per year for ophthalmology residency training in all of Canada. These numbers fluctuate per year, ranging from 30 to 37 spots. Of these, up to ten spots are at French-speaking universities in Quebec. At the end of the five years, the graduating ophthalmologist must pass the oral and written portions of the Royal College exam in either English or French.

Finland In Finland, physicians willing to become ophthalmologists must undergo a five-year specialization which includes practical training and theoretical studies.

India In India, after completing MBBS degree, postgraduate study in ophthalmology is required. The degrees are doctor of medicine, master of surgery, diploma in ophthalmic medicine and surgery, and diplomate of national board. The concurrent training and work experience are in the form of a junior residency at a medical college, eye hospital, or institution under the supervision of experienced faculty. Further work experience in the form of fellowship, registrar, or senior resident refines the skills of these eye surgeons. All members of the India Ophthalmologist Society and various state-level ophthalmologist societies hold regular conferences and actively promote continuing medical education.

Nepal In Nepal, to become an ophthalmologist, three years of postgraduate study is required after completing an MBBS degree. The postgraduate degree in ophthalmology is called medical doctor in ophthalmology. Currently, this degree is provided by Tilganga Institute of Ophthalmology, Tilganga, Kathmandu, BPKLCO, Institute of Medicine, TU, Kathmandu, BP Koirala Institute of Health Sciences, Dharan, Kathmandu University, Dhulikhel, and National Academy of Medical Science, Kathmandu. A few Nepalese citizens also study this subject in Bangladesh, China, India, Pakistan, and other countries. All graduates have to pass the Nepal Medical Council Licensing Exam to become a registered ophthalmologists in Nepal. The concurrent residency training is in the form of a PG student at a medical college, eye hospital, or institution according to the degree providing university's rules and regulations. Nepal Ophthalmic Society holds regular conferences and actively promotes continuing medical education.

Ireland In Ireland, the Royal College of Surgeons of Ireland grants membership and fellowship qualifications in conjunction with the Irish College of Ophthalmologists. Total postgraduate training involves an intern year, a minimum of three years of basic surgical training, and a further 4.5 years of higher surgical training. Clinical training takes place within public, Health Service Executive-funded hospitals in Dublin, Sligo, Limerick, Galway, Waterford, and Cork. A minimum of 8.5 years of training is required before eligibility to work in consultant posts. Some trainees take extra time to obtain MSc, M.D. or Ph.D. degrees and to undertake clinical fellowships in the UK, Australia, and the United States.

Pakistan In Pakistan, after MBBS, a four-year full-time residency program leads to an exit-level FCPS examination in ophthalmology, held under the auspices of the College of Physicians and Surgeons, Pakistan. The tough examination is assessed by both highly qualified Pakistani and eminent international ophthalmic consultants. As a prerequisite to the final examinations, an intermediate module, an optics and refraction module, and a dissertation written on a research project carried out under supervision is also assessed.

Moreover, a two-and-a-half-year residency program leads to an MCPS while a two-year training of DOMS is also being offered. For candidates in the military, a stringent two-year graded course, with quarterly assessments, is held under Armed Forces Post Graduate Medical Institute in Rawalpindi.

The M.S. in ophthalmology is also one of the specialty programs. In addition to programs for physicians, various diplomas and degrees for allied eye care personnel are also being offered to produce competent optometrists, orthoptists, ophthalmic nurses, ophthalmic technologists, and ophthalmic technicians in this field. These programs are

being offered, notably by the College of Ophthalmology and Allied Vision Sciences, in Lahore and the Pakistan Institute of Community Ophthalmology in Peshawar. Subspecialty fellowships also are being offered in the fields of pediatric ophthalmology and vitreoretinal ophthalmology. King Edward Medical University, Al Shifa Trust Eye Hospital Rawalpindi, and Al- Ibrahim Eye Hospital Karachi also have started a degree program in this field.

Philippines In the Philippines, Ophthalmology is considered a medical specialty that uses medicine and surgery to treat diseases of the eye. There is only one professional organization in the country that is duly recognized by the PMA and the PCS: the Philippine Academy of Ophthalmology. PAO and the state-standard Philippine Board of Ophthalmology regulate ophthalmology residency programs and board certification. To become a general ophthalmologist in the Philippines, a candidate must have completed a doctor of medicine degree or its equivalent, have completed an internship in Medicine, have passed the physician licensure exam, and have completed residency training at a hospital accredited by the Philippine Board of Ophthalmology . Attainment of board certification in ophthalmology from the PBO is essential in acquiring privileges in most major health institutions. Graduates of residency programs can receive further training in ophthalmology subspecialties, such as neuro-ophthalmology, retina, etc. by completing a fellowship program that varies in length depending on each program's requirements.

United Kingdom In the United Kingdom, three colleges grant postgraduate degrees in ophthalmology. The Royal College of Ophthalmologists and the Royal College of Surgeons of Edinburgh grant MRCOphth/FRCOphth and MRCSEd/FRCSEd,, the Royal College of Glasgow grants FRCS. Postgraduate work as a specialist registrar and one of these degrees is required for specialization in eye diseases. Such clinical work is within the NHS, with supplementary private work for some consultants.

Only 2.3 ophthalmologists exist per 100,000 populations in the UK – fewer pro rata than in any nations in the European Union.

United States In the United States, ophthalmologists must complete four years of undergraduate studies, four years of medical school, one year medical or general surgical residency, three years of ophthalmology residency, and optional one to two years of speciality training. Ophthalmologists are physicians who specialize in the eye and related structures. They perform medical and surgical eye care and also can write prescriptions for corrective lenses. They often deal with advanced forms of eye disease in patients with significant systemic illness.

Physicians must complete the requirements of continuing medical education to maintain licensure and for recertification. Professional bodies such as the American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery organize conferences, help physician members through continuing medical education programs for maintaining board certification, and provide political advocacy and peer support.

Notable ophthalmologists The following is a list of physicians who have significantly contributed to the field of ophthalmology: 18th–19th centuries Theodor Leber discovered Leber's congenital amaurosis, Leber's hereditary optic neuropathy, Leber's miliary aneurysm, and Leber's stellate neuroretinitis

Carl Ferdinand von Arlt, the elder, proved that myopia is largely due to an excessive axial length, published influential textbooks on eye disease, and ran annual eye clinics in needy areas long before the concept of volunteer eye camps became popular; his name is still attached to some disease signs, e.g., von Arlt's line in trachoma and his son, Ferdinand Ritter von Arlt, the younger, was also an ophthalmologist Jacques Daviel claimed to be the founder of modern cataract surgery in that he performed cataract extraction instead of needling the cataract or pushing it back into the vitreous; he is said to have carried out the technique on 206 patients in 1752–53, of which 182 were reported to be successful, however, these figures are not very credible, given the total lack of both anaesthesia and aseptic technique at that time Franciscus Donders published pioneering analyses of ocular biomechanics, intraocular pressure, glaucoma, and physiological optics and he made possible the prescribing of combinations of spherical and cylindrical lenses to treat astigmatism Joseph Forlenze, specialist in cataract surgery, became popular during the First French Empire, healing, among many, personalities such as the minister Jean-Étienne-Marie Portalis and the poet Ponce Denis Lebrun; he was nominated by Napoleon "chirurgien oculiste of the lycees, the civil hospices and all the charitable institutions of the departments of the Empire", and he also was known for his free interventions, mainly in favour of poor people Albrecht von Graefe probably the most important ophthalmologist of the nineteenth century, along with Helmholtz and Donders, one of the 'founding fathers' of ophthalmology as a specialty, he was a brilliant clinician and charismatic teacher who had an international influence on the development of ophthalmology, and was a pioneer in mapping visual field defects and diagnosis and treatment of glaucoma,and he introduced a cataract extraction technique that remained the standard for more than 100 years, and many other important surgical techniques such as iridectomy. He rationalised the use of many ophthalmically important drugs, including mydriatics and miotics; he also was the founder of one of the earliest ophthalmic societies and one of the earliest ophthalmic journals Allvar Gullstrand was a Nobel Prize-winner in 1911 for his research on the eye as a light-refracting apparatus, he described the 'schematic eye', a mathematical model of the human eye based on his measurements known as the 'optical constants' of the eye; his measurements are still used today Hermann von Helmholtz, a great German polymath, invented the ophthalmoscope and published important work on physiological optics, including colour vision José Rizal was a polymath who inspired the Philippine Revolution with his writings Julius Hirschberg in 1879 became the first to use an electromagnet to remove metallic foreign bodies from the eye and in 1886 developed the Hirschberg test for measuring strabismus Peter Adolph Gad, Danish ophthalmologist who founded the first eye infirmary in São Paulo, Brazil Socrate Polara founded the first dedicated ophthalmology clinic in Sicily in 1829, entirely as a philanthropic endeavor; later he was appointed as the first director of the ophthalmology department at the Grand Hospital of Palermo, Sicily, in 1831 after the Sicilian government became convinced of the importance of state support for the specialization Herman Snellen introduced the Snellen chart to study visual acuity 20th–21st centuries

Vladimir Petrovich Filatov contributed the tube flap grafting method, corneal transplantation, and preservation of grafts from cadaver eyes and tissue therapy; he founded the Filatov Institute of Eye Diseases and Tissue Therapy, Odessa, one of the leading eye-care institutes in the world Shinobu Ishihara, in 1918, invented the Ishihara Color Vision Test, a common method for determining Color blindness; he also made major contributions to the study of Trachoma and Myopia Ignacio Barraquer, in 1917, invented the first motorized vacuum instrument for intracapsular cataract extraction; he founded the Barraquer Clinic in 1941 and the Barraquer Institute in 1947 in Barcelona, Spain Ernst Fuchs was an Austrian ophthalmologist known for his discovery and description of numerous ocular diseases and abnormalities including Fuchs' dystrophy and Fuchs heterochromic iridocyclitis Tsutomu Sato pioneer in incisional refractive surgery, including techniques for astigmatism and the invention of radial keratotomy for myopia Jules Gonin was the "father of retinal detachment surgery" Sir Harold Ridley, in 1949, may have been the first to successfully implant an artificial intraocular lens after observing that plastic fragments in the eyes of wartime pilots were well tolerated; he fought for decades against strong reactionary opinions to have the concept accepted as feasible and useful Charles Schepens was the "father of modern retinal surgery" and developer of the Schepens indirect binocular ophthalmoscope whilst at Moorfields Eye Hospital; he was the founder of the Schepens Eye Research Institute, associated with Harvard Medical School and the Massachusetts Eye and Ear Infirmary, in Boston, Massachusetts Marshall M. Parks was the "father of pediatric ophthalmology" José Ignacio Barraquer was the "father of modern refractive surgery" and in the 1960s, he developed lamellar techniques, including keratomileusis and keratophakia, as well as the first microkeratome and corneal microlathe Frank M. Polack was an American ophthalmologist who designed the Polack forceps for corneal transplants Frederick T. Fraunfelder, ocular oncologist Tadeusz Krwawicz, in 1961, developed the first cryoprobe for intracapsular cataract extraction Svyatoslav Fyodorov was the "father of ophthalmic microsurgery" and he improved and popularized radial keratotomy, invented a surgical cure for cataract, and he developed scleroplasty Charles Kelman developed the ultrasound and mechanized irrigation and aspiration system for phacoemulsification, first allowing cataract extraction through a small incision Ioannis Pallikaris performed the first laser-assisted intrastromal keratomileusis surgery.

Occupational therapyOccupational therapy is the use of assessment and intervention to develop, recover, or maintain the meaningful activities, or occupations, of individuals, groups, or communities. It is an allied health profession performed by occupational therapists and occupational therapy assistants. OTs often works with people with mental health problems, disabilities, injuries, or impairments.

The American Occupational Therapy Association defines an occupational therapist as someone who "helps people across their lifespan participate in the things they want and need to do through the therapeutic use of everyday activities .

Common occupational therapy interventions include helping children with disabilities to participate fully in school and social situations, injury rehabilitation, and providing supports for older adults experiencing physical and cognitive changes."

Typically, occupational therapists are university-educated professionals and must pass a licensing exam to practice.

Occupational therapists often work closely with professionals in physical therapy, speech–language pathology, audiology, nursing, social work, psychology, medicine, and assistive technology.

History Early history The earliest evidence of using occupations as a method of therapy can be found in ancient times. In c. 100 BCE, Greek physician Asclepiades treated patients with a mental illness humanely using therapeutic baths, massage, exercise, and music. Later, the Roman Celsus prescribed music, travel, conversation and exercise to his patients. However, by medieval times the use of these interventions with people with mental illness was rare, if not nonexistent.

In 18th-century Europe, revolutionaries such as Philippe Pinel and Johann Christian Riel reformed the hospital system.

Instead of the use of metal chains and restraints, their institutions used rigorous work and leisure activities in the late 18th century. This was the Moral Treatment era, developed in Europe during the Age of Enlightenment, where the roots of occupational therapy lie. Although it was thriving in Europe, interest in the reform movement fluctuated in the United States throughout the 19th century. It re-emerged in the early decades of the 20th century as Occupational Therapy.

The Arts and Crafts movement that took place between 1860 and 1910 also impacted occupational therapy. In the US, a recently industrialized country, the arts and crafts societies emerged against the monotony and lost autonomy of factory work. Arts and crafts were used as a way of promoting learning through doing, provided a creative outlet, and served as a way to avoid boredom during long hospital stays.

Eleanor Clarke Slagle is considered to be the “mother” of occupational therapy. Slagle, who was one of the founding members of the National Society for the Promotion of Occupational Therapy, proposed habit training as a primary occupational therapy model of treatment. Based on the philosophy that engagements in meaningful routines shape a person's wellbeing, habit training focused on creating structure and balance between work, rest and leisure. Although habit training was initially developed to treat individuals with mental health conditions, its basic tenets are apparent in modern treatment models that are utilized across a wide scope of client populations.

In 1915 Slagle opened the first occupational therapy training program, the Henry B. Favill School of Occupations, at Hull House in Chicago. Slagle went on to serve as both AOTA president and secretary. In 1954, AOTA created the Eleanor Clarke Slagle Lectureship Award in her honor. Each year, this award recognizes a member of AOTA “who has creatively contributed to the development of the body of knowledge of the profession through research, education, or clinical practice.”

Development into a health profession The health profession of occupational therapy was conceived in the early 1910s as a reflection of the Progressive Era. Early professionals merged highly valued ideals, such as having a strong work ethic and the importance of crafting with one's own hands with scientific and medical principles. William Rush Dunton, one of the founders of NSPOT and visionary figure in the first decades of the profession struggled with "the cumbersomeness of the term occupational therapy", as it lacked the "exactness of meaning which is possessed by scientific terms". Other titles such as "workcure","ergo therapy", and "creative occupations" were discussed as substitutes, but ultimately, none possessed the broad meaning that the practice of occupational therapy demanded in order to capture the many forms of treatment that existed from the beginning.

The emergence of occupational therapy challenged the views of mainstream scientific medicine. Instead of focusing purely on the medical model, occupational therapists argued that a complex combination of social, economic, and biological reasons cause dysfunction. Principles and techniques were borrowed from many disciplines—including but not limited to physical therapy, nursing, psychiatry, rehabilitation, self-help, orthopedics, and social work—to enrich the profession's scope. Between 1900 and 1930, the founders defined the realm of practice and developed supporting theories. By the early 1930s, AOTA had established educational guidelines and accreditation procedures.

The early twentieth century was a time in which the rising incidence of disability related to industrial accidents, tuberculosis, World War I, and mental illness brought about an increasing social awareness of the issues involved. The entry of the United States into World War I was also a crucial event in the history of the profession. Up until this time, occupational therapy had been concerned primarily with the treatment of people with mental illness. However, U.S. involvement in the Great War and the escalating numbers of injured and disabled soldiers presented a daunting challenge to those in command. The military enlisted the assistance of NSPOT to recruit and train over 1,200 "reconstruction aides" to help with the rehabilitation of those wounded in the war. With entry into World War II and the ensuing skyrocketing demand for occupational therapists to treat those injured in the war, the field of occupational therapy underwent dramatic growth and change. Occupational therapists needed to be skilled not only in the use of constructive activities such as crafts, but also increasingly in the use of activities of daily living. That said, occupational science continues to be largely theory driven to the present day, and its application to clinical practice is frequently questioned.

In addition, occupational therapy practitioner's roles have expanded to include political advocacy ; for example, in 2010 PL 111-148 titled the Patient Protection and Affordable Care Act had a habilitation clause that was passed in large part due to AOTA's political efforts as noted in AOTA's Centennial website . Furthermore, occupational therapy practitioners have been striving personally and professionally toward concepts of occupational justice and other human rights issues that have both local and global impacts. The World Federation of Occupational Therapist's Resource Centre has many position statements on occupational therapy's roles regarding their participation in human rights issues.

Philosophical underpinnings The philosophy of occupational therapy has evolved over the history of the profession. The philosophy articulated by the founders owed much to the ideals of romanticism, pragmatism and humanism, which are collectively considered the fundamental ideologies of the past century.

One of the most widely cited early papers about the philosophy of occupational therapy was presented by Adolf Meyer, a psychiatrist who had emigrated to the United States from Switzerland in the late 19th century and who was invited to present his views to a gathering of the new Occupational Therapy Society in 1922. At the time, Dr. Meyer was one of the leading psychiatrists in the United States and head of the new psychiatry department and Phipps Clinic at Johns Hopkins University in Baltimore, Maryland.

William Rush Dunton, a supporter of the National Society for the Promotion of Occupational Therapy, now the American Occupational Therapy Association, sought to promote the ideas that occupation is a basic human need, and that occupation is therapeutic. From his statements came some of the basic assumptions of occupational therapy, which include: Occupation has a positive effect on health and well-being.

Occupation creates structure and organizes time.

Occupation brings meaning to life, culturally and personally.

Occupations are individual. People value different occupations.

These assumptions have been developed over time and are the basis of the values that underpin the Codes of Ethics issued by the national associations. The relevance of occupation to health and well-being remains the central theme.

In the 1950s, criticism from medicine and the multitude of disabled World War II veterans resulted in the emergence of a more reductionistic philosophy. While this approach led to developments in technical knowledge about occupational performance, clinicians became increasingly disillusioned and re-considered these beliefs. As a result, client centeredness and occupation have re-emerged as dominant themes in the profession. Over the past century, the underlying philosophy of occupational therapy has evolved from being a diversion from illness, to treatment, to enablement through meaningful occupation. Some values formulated by the American Occupational Therapy Association have been critiqued as being therapist-centric and do not reflect the modern reality of multicultural practice.

In recent times occupational therapy practitioners have challenged themselves to think more broadly about the potential scope of the profession, and expanded it to include working with groups experiencing occupational injustice stemming from sources other than disability. Examples of new and emerging practice areas would include therapists working with refugees, children experiencing obesity, and people experiencing homelessness.

Practice frameworks An occupational therapist works systematically with a client through a sequence of actions called the occupational therapy process. There are several versions of this process as described by numerous scholars. All practice frameworks include the components of evaluation, intervention, and outcomes. This process provides a framework through which occupational therapists assist and contribute to promoting health and ensures structure and consistency among therapists.

The Occupational Therapy Practice Framework is the core competency of occupational therapy in the United States. The OTPF framework is divided into two sections: domain and process. The domain includes environment, client factors, such as the individual's motivation, health status, and status of performing occupational tasks. The domain looks at the contextual picture to help the occupational therapist understand how to diagnose and treat the patient. The process is the actions taken by the therapist to implement a plan and strategy to treat the patient. These occupations can be goaldirected, task-oriented, purposeful, culturally relevant, role specific, individually tailored, or community-oriented, depending on one's values, beliefs, context, and environment.

The following are examples of such occupations: Activities of daily living The OTPF-3 defines ADLs as daily activities that are required to take care of one's self and body, which are instrumental to one's health, well-being, and social participation.

Examples of ADL's include: bathing, showering, toileting and toilet hygiene, dressing, swallowing/eating, feeding, functional mobility, personal hygiene and grooming, and sexual activity.

Instrumental activities of daily living The Canadian Institute for Health Information found that between 2006-2010 nearly half of occupational therapists worked in hospitals, 31.8% worked in the community, and 11.4% worked in a professional practice.

Areas of practice The broad spectrum of OT practice makes it difficult to categorize the areas of practice, especially considering the differing health care systems globally. In this section, the categorization from the American Occupational Therapy Association is used.

Children and youth Occupational therapists work with infants, toddlers, children, youth, and their families in a variety of settings, including schools, clinics, homes, hospitals, and the community. Assessment of a person's ability to engage in daily, meaningful occupations is the initial step of occupational therapy intervention and involves evaluating a young person's occupational performance in areas of feeding, playing, socializing, daily living skills, or attending school. Occupational therapists take into consideration the strengths and weaknesses of a child's underlying skills which may be physical, cognitive, or emotional in nature, as well as the context and environmental demands at play. In planning treatment, occupational therapists work in collaboration with parents, caregivers, teachers, or the children and teens themselves in order to develop functional goals within a variety of occupations meaningful to the young client. Early intervention is an extremely important aspect of the daily functioning of a child between the ages of birth-3 years old. This area of practice sets the tone or standard for therapy in the school setting. OT's who practice in early intervention develop a family's ability to care for their child with special needs and promote his or her function and participation in the most natural environment as possible. Each child is required to have an Individualized Family Service Plan that focuses on the family's goals for the child. It's possible for an OT to serve as the family's service coordinator and facilitate the team process for creating an IFSP for each eligible child.

Objectives that an occupational therapist addresses with children and youth may take a variety of forms. For example: Providing splinting and caregiver education in a hospital burn unit.

Facilitating handwriting development through providing intervention to develop fine motor and writing readiness skills in school-aged children.

Providing individualized treatment for sensory processing difficulties.

Teaching coping skills to a child with generalized anxiety disorder.

Consulting with teachers, counselors, social workers, parents/ caregivers, or any person that works with children regarding modifications, accommodations and supports in a variety of areas, such as sensory processing, motor planning, visual processing, sequencing, transitions between schools, etc.

Instructing caregivers in regard to mealtime intervention for children with autism who have feeding difficulties.

In the United States, pediatric occupational therapists work in the school setting as a "related service" for children with an Individual Education Plan . Related services are “developmental, corrective, and other supportive services as are required to assist a child with a disability to benefit from special education,” and include a variety of professions such as

speech–language pathology and audiology services, interpreting services, psychological services, and physical and occupational therapy.

As a related service, occupational therapists work with children with varying disabilities to address those skills needed to access the special education program and support academic achievement and social participation throughout the school day . In doing so, occupational therapists help children fulfill their role as students and prepare them to transition to post-secondary education, career and community integration .

Occupational therapists have specific knowledge to increase participation in school routines throughout the day, including: Modification of the school environment to allow physical access for children with disabilities Provide assistive technology to support student success Helping to plan instructional activities for implementation in the classroom Support the needs of students with significant challenges such as helping to determine methods for alternate assessment of learning Helping students develop the skills necessary to transition to post-high school employment, independent living or further education .

Other settings, such as homes, hospitals, and the community are important environments where occupational therapists work with children and teens to promote their independence in meaningful, daily activities.

Recognition of occupational therapy programs and services for children and youth is increasing worldwide. Occupational therapy for both children and adults is now recognized by the United Nations as a human right which is linked to the social determinants of health. As of 2018, there are over 500,000 occupational therapists working worldwide and 778 academic institutions providing occupational therapy instruction.

Health and wellness According to the American Occupational Therapy Association’s Occupational Therapy Practice Framework, 3rd Edition, the domain of occupational therapy is described as "Achieving health, well-being, and participation in life through engagement in occupation". Occupational therapy practitioners have a distinct value in their ability to utilize daily occupations to achieve optimal health and well-being. By examining an individual's roles, routines, environment, and occupations, occupational therapists can identify the barriers in achieving overall health, well-being and participation.

Occupational therapy practitioners can intervene at primary, secondary and tertiary levels of intervention to promote health and wellness. It can be addressed in all practice settings to prevent disease and injuries, and adapt healthy lifestyle practices for those with chronic diseases. Two of the occupational therapy programs that have emerged targeting health and wellness are the Lifestyle Redesign Program and the REAL Diabetes Program.

Occupational therapy interventions for health and wellness vary in each setting: Outpatient Occupational therapy practitioners conduct 1:1 treatment sessions and group interventions to address: leisure, health literacy and education, modified physical activity, stress/anger management, healthy meal preparation, and medication management.

Acute care Occupational therapy practitioners conduct 1:1 treatment sessions, group interventions and promote hospital-wide programs targeting: leisure, stress management, pain management techniques, physical activity, healthy food recommendations, and medication management.

Community-based Occupational therapy practitioners develop and implement community wide programs to assist in prevention of diseases and encourage healthy lifestyles by: conducting education classes for prevention, facilitating gardening, offering ergonomic assessments, and offering pleasurable leisure and physical activity programs.

Mental health The occupational therapy profession believes that the health of an individual is fostered through active engagement in one's occupations. When a person is experiencing any mental health need, his or her ability to actively participate in occupations may be hindered. For example, if a person has depression or anxiety, he or she may experience interruptions in sleep, difficulty completing self-care tasks, decreased motivation to participate in leisure activities, decreased concentration for school or job related work, and avoidance of social interactions. Occupational therapy practitioners possess the educational knowledge base in mental health and can contribute to the efforts in mental health promotion, prevention, and intervention. Occupational therapy practitioners can provide services that focus on social emotional well-being, prevention of negative behaviors, early detection through screenings, and intensive intervention. Occupational therapy practitioners can work directly with clients, provide professional development for staff, and work in collaboration with other team members and families. For instance, occupational therapists are specifically skilled at understanding the relationship between the demands of a task and the person's abilities. With this knowledge, practitioners are able to devise an intervention plan to facilitate successful participation in meaningful occupations. Occupational therapy services can focus on engagement in occupation to support participation in areas related to school, education, work, play, leisure, ADLs, and instrumental ADLs .

Occupational therapy utilizes the public health approach to mental health which emphasizes the promotion of mental health as well as the prevention of, and intervention for, mental illness. This model highlights the distinct value of occupational therapists in mental health promotion, prevention, and intensive interventions across the lifespan . Below are the three major levels of service: Tier 3: intensive interventions Intensive interventions are provided for individuals with identified mental, emotional, or behavioral disorders that limit daily functioning, interpersonal relationships, feelings of emotional well-being, and the ability to cope with challenges in daily life. Occupational therapy practitioners are committed to the recovery model which focuses on enabling persons with mental health challenges through a client-centered process to live a meaningful life in the community and reach their potential .

The focus of intensive interventions is engagement in occupation to foster recovery or “reclaiming mental health” resulting in optimal levels of community participation, daily functioning, and quality of life; functional assessment and intervention ; identification and implementation of healthy habits, rituals, and routines to support wellness.

Tier 2: targeted services Targeted services are designed to prevent mental health problems in persons who are at risk of developing mental health challenges, such as those who have emotional experiences, situational stressors or genetic factors . Occupational

therapy practitioners are committed to early identification of and intervention for mental health challenges in all settings.

The focus of targeted services is engagement in occupations to promote mental health and diminish early symptoms; small, therapeutic groups ; environmental modifications to enhance participation Tier 1: universal services Universal services are provided to all individuals with or without mental health or behavioral problems, including those with disabilities and illnesses . Occupational therapy services focus on mental health promotion and prevention for all: encouraging participation in health-promoting occupations; fostering self-regulation and coping strategies; promoting mental health literacy. Occupational therapy practitioners develop universal programs and embed strategies to promote mental health and well-being in a variety of settings, from schools to the workplace.

The focus of universal services is universal programs to help all individuals successfully participate in occupations that promote positive mental health; educational and coaching strategies with a wide range of relevant stakeholders focusing on mental health promotion and prevention; the development of coping strategies and resilience; environmental modifications and supports to foster participation in health-promoting occupations.

Productive aging Occupational therapists work with older adults to maintain independence, participate in meaningful activities, and live fulfilling lives. Some examples of areas that occupational therapists address with older adults are driving, aging in place, low vision, and dementia or Alzheimer's disease. When addressing driving, driver evaluations are administered to determine if drivers are safe behind the wheel. To enable independence of older adults at home, occupational therapists perform falls risk assessments; assess clients functioning in their homes, and recommend specific home modifications.

When addressing low vision, occupational therapists modify tasks and the environment. While working with individuals with AD, occupational therapists focus on maintaining quality of life, ensuring safety, and promoting independence.

Geriatrics/productive aging Occupational therapists address all aspects of aging from health promotion to treatment of various disease processes.

The goal of occupational therapy for older adults is to ensure that older adults can maintain independence and reduce health care costs associated with hospitalization and institutionalization. In the community, occupational therapists can assess an older adults ability to drive and if they are safe to do so. If it is found that an individual is not safe to drive the occupational therapist can assist with finding alternate transit options. Occupational therapists also work with older adults in their home as part of home care. In the home, an occupational therapist can work on such things as fall prevention, maximizing independence with activities of daily living, ensuring safety and being able to stay in the home for as long as the person wants. An occupational therapist can also recommend home modifications to ensure safety in the home. Many older adults suffer from chronic conditions such as diabetes, arthritis, and cardiopulmonary conditions.

Occupational therapists can help manage these conditions by offering education on energy conservation strategies or coping strategies. Not only do occupational therapists work with older adults in their homes, they also work with older adults in hospitals, nursing homes and post-acute rehabilitation. In nursing homes, the role of the occupational therapist is to work with clients and caregivers on education for safe care, modifying the environment, positioning needs and enhancing IADL skills to name a few. In post-acute rehabilitation, occupational therapists work with clients to get them back home and to their prior level of function after a hospitalization for an illness or accident. Occupational therapists also play a unique role for those with dementia. The therapist may assist with modifying the environment to ensure safety as the disease progresses along with caregiver education to prevent burnout. Occupational therapists also play a role in palliative and hospice care. The goal at this stage of life is to ensure that the roles and occupations that the

individual finds meaningful continue to be meaningful. If the person is no longer able to perform these activities, the occupational therapist can offer new ways to complete these tasks while taking into consideration the environment along with psychosocial and physical needs. Not only do occupational therapists work with older adults in traditional settings, they also work in senior centre's and ALFs. Visual impairment Visual impairment is one of the top 10 disabilities among American adults. Occupational therapists work with other professions, such as optometrists, ophthalmologists, and certified low vision therapists, to maximize the independence of persons with a visual impairment by using their remaining vision as efficiently as possible. AOTA's promotional goal of “Living Life to Its Fullest” speaks to who people are and learning about what they want to do, particularly when promoting the participation in meaningful activities, regardless of a visual impairment. A population that may benefit from occupational therapy includes older adults, persons with traumatic brain injury, adults with potential to return to driving, and children with visual impairments.

Visual impairments addressed by occupational therapists may be characterized into 2 types including low vision or a neurological visual impairment. An example of a neurological impairment is a cortical visual impairment which is defined as “...abnormal or inefficient vision resulting from a problem or disorder affecting the parts of brain that provide sight”. The following section will discuss the role of occupational therapy when working with the visually impaired.

Occupational therapy for older adults with low vision includes task analysis, environmental evaluation, and modification of tasks or the environment as needed. Many occupational therapy practitioners work closely with optometrists and ophthalmologists to address visual deficits in acuity, visual field, and eye movement in people with traumatic brain injury, including providing education on compensatory strategies to complete daily tasks safely and efficiently. Adults with a stable visual impairment may benefit from occupational therapy for the provision of a driving assessment and an evaluation of the potential to return to driving. Lastly, occupational therapy practitioners enable children with visual impairments to complete self care tasks and participate in classroom activities using compensatory strategies.

Adult rehabilitation Occupational therapists address the need for rehabilitation following an injury or impairment. When planning treatment, occupational therapists address the physical, cognitive, psychosocial, and environmental needs involved in adult populations across a variety of settings.

Occupational therapy in adult rehabilitation may take a variety of forms: Working with adults with autism at day rehabilitation programs to promote successful relationships and community participation through instruction on social skills Increasing the quality of life for an individual with cancer by engaging them in occupations that are meaningful, providing anxiety and stress reduction methods, and suggesting fatigue management strategies Coaching individuals with hand amputations how to put on and take off a myoelectrically controlled limb as well as training for functional use of the limb Communicating via telehealth methods as a service delivery model for clients who live in rural areas Working with adults who have had a stroke to regain their activities of daily living Assistive technology

Occupational therapy practitioners, or occupational therapists, are uniquely poised to educate, recommend, and promote the use of assistive technology to improve the quality of life for their clients. OTs are able to understand the unique needs of the individual in regards to occupational performance and have a strong background in activity analysis to focus on helping clients achieve goals. Thus, the use of varied and diverse assistive technology is strongly supported within occupational therapy practice models.

Travel occupational therapy Because of the rising need for occupational therapy practitioners in the U.S., many facilities are opting for travel occupational therapy practitioners—who are willing to travel, often out of state, to work temporarily in a facility.

Assignments can range from 8 weeks to 9 months, but typically last 13–26 weeks in length. Travel therapists work in many different settings, but the highest need for therapists are in home health and skilled nursing facility settings. There are no further educational requirements needed to be a travel occupational therapy practitioner; however, there may be different state licensure guidelines and practice acts that must be followed. According to Zip Recruiter, as of July 2019, the national average salary for a full-time travel therapist is $86,475 with a range between $62,500 to $100,000 across the United States. Most commonly, travel occupational therapists enter the industry between the ages of 21–30.

Occupational justice The practice area of occupational justice relates to the “benefits, privileges and harms associated with participation in occupations” and the effects related to access or denial of opportunities to participate in occupations. This theory brings attention to the relationship between occupations, health, well-being, and quality of life. Occupational justice can be approached individually and collectively. The individual path includes disease, disability, and functional restrictions. The collective way consists of public health, gender and sexual identity, social inclusion, migration, and environment. The skills of occupational therapy practitioners enable them to serve as advocates for systemic change, impacting institutions, policy, individuals, communities, and entire populations. Examples of populations that experience occupational injustice include refugees, prisoners, homeless persons, survivors of natural disasters, individuals at the end of their life, people with disabilities, elderly living in residential homes, individuals experiencing poverty, children, immigrants, and LGBTQI+ individuals.

For example, the role of an occupational therapist working to promote occupational justice may include: Analyzing task, modifying activities and environments to minimize barriers to participation in meaningful activities of daily living.

Addressing physical and mental aspects that may hinder a person's functional ability.

Provide intervention that is relevant to the client, family, and social context.

Contribute to global health by advocating for individuals with disabilities to participate in meaningful activities on a global level. Occupation therapists are involved with the World Health Organization, non-governmental organizations and community groups and policymaking to influence the health and well-being of individuals with disabilities worldwide Occupational therapy practitioners’ role in occupational justice is not only to align with perceptions of procedural and social justice but to advocate for the inherent need of meaningful occupation and how it promotes a just society, wellbeing, and quality of life among people relevant to their context. It is recommended to the clinicians to consider occupational justice in their everyday practice to promote the intention of helping people participate in tasks that they want and need to do.

Occupational injustice In contrast, occupational injustice relates to conditions wherein people are deprived, excluded or denied of opportunities that are meaningful to them. Types of occupational injustices and examples within the OT practice include: Occupational deprivation: The exclusion from meaningful occupations due to external factors that are beyond the person's control. As an example, a person who has difficulties with functional mobility may find it challenging to reintegrate into the community due to transportation barriers.

Occupational apartheid: The exclusion of a person in chosen occupations due to personal characteristics such as age, gender, race, nationality or socioeconomic status. An example can be seen in children with developmental disabilities from low socioeconomic backgrounds whose families would opt out from therapy due to financial constraints.

Occupational marginalization: Relates to how implicit norms of behavior or societal expectations prevents a person from engaging in a chosen occupation. As an example, a child with physical impairments may only be offered table-top leisure activities instead of sports as an extracurricular activity due to the functional limitations caused by his physical impairments.

Occupational imbalance: The limited participation in a meaningful occupation brought about by another role in a different occupation. This can be seen in the situation of a caregiver of a person with disability who also has to fulfill other roles such as being a parent to other children, a student or a worker.

Occupational alienation: The imposition of an occupation which does not hold meaning for that person. In the OT profession, this manifests in the provision of rote activities which does not really relate to the goals or the interest of the client.

Within occupational therapy practice, injustice may ensue in situations wherein professional dominance, standardized treatments, laws and political conditions create a negative impact on the occupational engagement of our clients.

Community-based practice crosses all of the categories within which OTs practice from physical to cognitive, mental health to spiritual, all types of clients may be seen in community-based settings. The role of the OT also may vary, from advocate to consultant, direct care provider to program designer, adjunctive services to therapeutic leader. More generally they are defined as "those aspects which influence our perceptions, decisions and practice".

Person Environment Occupation Performance Model The Person Environment Occupation Performance model was originally published in 1991 and describes an individual's performance based on four elements including: environment, person, performance and occupation. The model focuses on the interplay of these components and how this interaction works to inhibit or promote successful engagement in occupation.

Occupation-Focused Practice Models Occupational Therapy Intervention Process Model Occupational Performance Process Model Model of Human Occupation

MOHO was first published in 1980. It explains how people select, organise and undertake occupations within their environment. The model is supported with evidence generated over thirty years and has been successfully applied throughout the world.

Canadian Model of Occupational Performance and Engagement Occupational Performances Model – Australia The OPM was conceptualized in 1986 with its current form launched in 2006. The OPM illustrates the complexity of occupational performance, the scope of occupational therapy practice, and provides a framework for occupational therapy education.

Kawa Model The Biopsychosocial Model The biopsychosocial model takes into account how disease and illness can be impacted by social, environmental, psychological and body functions. The biopsychosocial model is unique in that it takes the client's subjective experience and the client-provider relationship as factors to wellness. This model also factors in cultural diversity as many countries have different societal norms and beliefs. This is a multifactorial and multi-dimensional model to understand not only the cause of disease but also a person-centered approach that the provider has more of a participatory and reflective role.

Frames of reference Frames of reference are an additional knowledge base for the occupational therapist to develop their treatment or assessment of a patient or client group. Though there are conceptual models that allow the therapist to conceptualist the occupational roles of the patient, it is often important to use further reference to embed clinical reasoning.

Therefore, many occupational therapists will use additional frames of reference to both assess and then develop therapy goals for their patients or service users.

Biomechanical frame of reference The biomechanical frame of reference is primarily concerned with motion during occupation. It is used with individuals who experience limitations in movement, inadequate muscle strength or loss of endurance in occupations. The frame of reference was not originally compiled by occupational therapists, and therapists should translate it to the occupational therapy perspective, to avoid the risk of movement or exercise becoming the main focus.

Rehabilitative Neurofunctional Dynamic systems theory Client-centered frame of reference This frame of reference is developed from the work of Carl Rogers. It views the client as the center of all therapeutic activity, and the client's needs and goals direct the delivery of the occupational therapy Process.

Cognitive-behavioral frame of reference Ecology of human performance model

The recovery model Sensory integration Sensory integration framework is commonly implemented in clinical, community, and school-based occupational therapy practice. It is most frequently used with children with developmental delays and developmental disabilities such as autism spectrum disorder and dyspraxia. Core features of sensory integration in treatment include providing opportunities for the client to experience and integrate feedback using multiple sensory systems, providing therapeutic challenges to the client's skills, integrating the client's interests into therapy, organizing of the environment to support the client's engagement, facilitating a physically safe and emotionally supportive environment, modifying activities to support the client's strengths and weaknesses, and creating sensory opportunities within the context of play to develop intrinsic motivation. While sensory integration is traditionally implemented in pediatric practice, there is emerging evidence for the benefits of sensory integration strategies for adults.

ICF The International Classification of Functioning, Disability and Health is a framework to measure health and ability by illustrating how these components impact one's function. This relates very closely to the Occupational Therapy Practice Framework, as it is stated that "the profession's core beliefs are in the positive relationship between occupation and health and its view of people as occupational beings". The ICF is built into the 2nd edition of the practice framework.

Activities and participation examples from the ICF overlap Areas of Occupation, Performance Skills, and Performance Patterns in the framework. The ICF also includes contextual factors that relate to the framework's context. In addition, body functions and structures classified within the ICF help describe the client factors described in the Occupational Therapy Practice Framework. Further exploration of the relationship between occupational therapy and the components of the ICIDH-2, which later became the ICF) was conducted by McLaughlin Gray.

It is noted in the literature that occupational therapists should use specific occupational therapy vocabulary along with the ICF in order to ensure correct communication about specific concepts. The ICF might lack certain categories to describe what occupational therapists need to communicate to clients and colleagues. It also may not be possible to exactly match the connotations of the ICF categories to occupational therapy terms. The ICF is not an assessment and specialized occupational therapy terminology should not be replaced with ICF terminology. The ICF is an overarching framework for current therapy practices.

Global occupational therapy Occupational therapy is practiced around the world and can be translated in practice to many different cultures and environments. The construct of occupation is shared throughout the profession regardless of country, culture and context. Occupation and the active participation in occupation is now seen as a human right and is asserted as a strong influence in health and well-being.

As the profession grows there is a lot of people who are travelling across countries to work as occupational therapists for better work or opportunities. Under this context, every occupational therapist is required to adapt to a new culture, foreign to their own. Understanding cultures and its communities are crucial to occupational therapy ethos. Effective occupational therapy practice includes acknowledging the values and social perspectives of each client and their families. Harnessing culture and understanding what is important to the client is truly a faster way towards independence.

The World Federation of Occupational Therapists is an international voice of the profession and is a membership network of occupational therapists worldwide. WFOT supports the international practice of occupational therapy

through collaboration across countries. WFOT currently includes over 100 member country organizations, 550,000 occupational therapy practitioners, and 900 approved educational programs.

The profession celebrates World Occupational Therapy Day on the 27th of October annually to increase visibility and awareness of the profession, promoting the profession's development work at a local, national and international platform. WFOT has been in close collaboration with the World Health Organization since 1959, working together in programmes that aim to improve world health. WFOT supports the vision for healthy people, in alignment with the United Nations 17 Sustainable Development Goals, which focuses on "ending poverty, fighting inequality and injustice, tackling climate change and promoting health". Occupational therapy is a major player in enabling individuals and communities to engage in "chosen and necessary occupations" and in "the creation of more meaningful lives".

See also Occupational apartheid Occupational therapy in the United Kingdom Occupational therapy in the management of cerebral palsy Occupational therapy and substance use disorder.

PharmacovigilancePharmacovigilance, also known as drug safety, is the pharmacological science relating to the collection, detection, assessment, monitoring, and prevention of adverse effects with pharmaceutical products. The etymological roots for the word "pharmacovigilance" are: pharmakon and vigilare . As such, pharmacovigilance heavily focuses on adverse drug reactions, or ADRs, which are defined as any response to a drug which is noxious and unintended, including lack of efficacy. Medication errors such as overdose, and misuse and abuse of a drug as well as drug exposure during pregnancy and breastfeeding, are also of interest, even without an adverse event, because they may result in an adverse drug reaction.

Information received from patients and healthcare providers via pharmacovigilance agreements, as well as other sources such as the medical literature, plays a critical role in providing the data necessary for pharmacovigilance to take place. In fact, in order to market or to test a pharmaceutical product in most countries, adverse event data received by the license holder must be submitted to the local drug regulatory authority.

Ultimately, pharmacovigilance is concerned with identifying the hazards associated with pharmaceutical products and with minimizing the risk of any harm that may come to patients. Companies must conduct a comprehensive drug safety and pharmacovigilance audit to assess their compliance with worldwide laws, regulations, and guidance.

Terms commonly used in drug safety Pharmacovigilance has its own unique terminology that is important to understand. Most of the following terms are used within this article and are peculiar to drug safety, although some are used by other disciplines within the pharmaceutical sciences as well.

Adverse drug reaction is a side effect occurring with a drug where a positive causal relationship between the event and the drug is thought, or has been proven, to exist.

Adverse event is a side effect occurring with a drug. By definition, the causal relationship between the AE and the drug is unknown.

Benefits are commonly expressed as the proven therapeutic good of a product but should also include the patient's subjective assessment of its effects.

Causal relationship is said to exist when a drug is thought to have caused or contributed to the occurrence of an adverse drug reaction.

Clinical trial refers to an organized program to determine the safety and/or efficacy of a drug in patients. The design of a clinical trial will depend on the drug and the phase of its development.

Control group is a group of individual patients that is used as a standard of comparison within a clinical trial. The control group may be taking a placebo or where a different active drug is given as a comparator.

DE challenge and challenge refer to a drug being stopped and restarted in a patient, respectively. A positive challenge has occurred, for example, when an adverse event abates or resolves completely following the drug's discontinuation. A positive challenge has occurred when the adverse event re-occurs after the drug is restarted. DE challenge and rechallenge play an important role in determining whether a causal relationship between an event and a drug exists.

The activities involved in pharmacovigilance are:

Case-control study.

Prospective study.

Population statistics.

Intensive event report.

The spontaneous report in the case is the population of the single case report.

Effectiveness is the extent to which a drug works under real world circumstances, i.e., clinical practice.

Efficacy is the extent to which a drug works under ideal circumstances, i.e., in clinical trials.

Event refers to an adverse event .

Harm is the nature and extent of the actual damage that could be or has been caused.

Implied causality refers to spontaneously reported AE cases where the causality is always presumed to be positive unless the reporter states otherwise.

Individual Case Safety Report is an adverse event report for an individual patient.

Life-threatening refers to an adverse event that places a patient at the immediate risk of death.

Phase refers to the four phases of clinical research and development: I – small safety trials early on in a drug's development; II – medium-sized trials for both safety and efficacy; III – large trials, which includes key trials; IV – large, post-marketing trials, typically for safety reasons. There are also intermediate phases designated by an "a" or "b", e.g.

Phase IIb. Risk is the probability of harm being caused, usually expressed as a percent or ratio of the treated population.

Risk factor is an attribute of a patient that may predispose, or increase the risk, of that patient developing an event that may or may not be drug-related. For instance, obesity is considered a risk factor for a number of different diseases and, potentially, ADRs. Others would be high blood pressure, diabetes, possessing a specific mutated gene, for example, mutations in the BRCA1 and BRCA2 genes increase propensity to develop breast cancer.

Signal is a new safety finding within safety data that requires further investigation. There are three categories of signals: confirmed signals where the data indicate that there is a causal relationship between the drug and the AE; refuted signals where after investigation the data indicate that no causal relationship exists; and unconfirmed signals which require further investigation such as the conducting of a post-marketing trial to study the issue.

Temporal relationship is said to exist when an adverse event occurs when a patient is taking a given drug. Although a temporal relationship is absolutely necessary in order to establish a causal relationship between the drug and the AE, a temporal relationship does not necessarily in and of itself proves that the event was caused by the drug.

Triage refers to the process of placing a potential adverse event report into one of three categories: 1) non-serious case; 2) serious case; or 3) no case.

Adverse event reporting The activity that is most commonly associated with pharmacovigilance, and which consumes a significant amount of resources for drug regulatory authorities and drug safety departments in pharmaceutical companies, is that of adverse

event reporting. Adverse event reporting involves the receipt, triage, data entry, assessment, distribution, reporting, and archiving of AE data and documentation. The source of AE reports may include: spontaneous reports from healthcare professionals or patients; solicited reports from patient support programs; reports from clinical or post-marketing studies; reports from literature sources; reports from the media; and reports reported to drug regulatory authorities themselves. For pharmaceutical companies, AE reporting is a regulatory requirement in most countries. AE reporting also provides data to these companies and drug regulatory authorities that play a key role in assessing the risk-benefit profile of a given drug. The following are several facets of AE reporting: Individual Case Safety Report One of the fundamental principles of adverse event reporting is the determination of what constitutes an Individual Case Safety Report. During the triage phase of a potential adverse event report, it is important to determine if the "four elements" of a valid ICSR are present: an identifiable patient, an identifiable reporter, a suspect drug, and an adverse event.

If one or more of these four elements is missing, the case is not a valid ICSR. Although there are no exceptions to this rule there may be circumstances that may require a judgment call. For example, the term "identifiable" may not always be clear-cut. If a physician reports that he/she has a patient X taking drug Y who experienced Z, but refuses to provide any specifics about patient X, the report is still a valid case even though the patient is not specifically identified. This is because the reporter has first-hand information about the patient and is identifiable to the physician. Identifiability is important so as not only to prevent duplicate reporting of the same case, but also to permit follow-up for additional information.

The concept of identifiability also applies to the other three elements. Although uncommon, it is not unheard of for fictitious adverse event "cases" to be reported to a company by an anonymous individual trying to damage the company's reputation or a company's product. In these and all other situations, the source of the report should be ascertained . But anonymous reporting is also important, as whistle blower protection is not granted in all countries. In general, the drug must also be specifically named. Note that in different countries and regions of the world, drugs are sold under various tradenames. In addition, there are a large number of generics which may be mistaken for the trade product. Finally, there is the problem of counterfeit drugs producing adverse events. If at all possible, it is best to try to obtain the sample which induced the adverse event, and send it to either the EMA, FDA or other government agency responsible for investigating AE reports.

If a reporter can't recall the name of the drug they were taking when they experienced an adverse event, this would not be a valid case. This concept also applies to adverse events. If a patient states that they experienced "symptoms", but cannot be more specific, such a report might technically be considered valid, but will be of very limited value to the pharmacovigilance department of the company or to drug regulatory authorities.

The activities involved in pharmacovigilance are: 1- Case-control study .

2- Prospective study .

3- Population statistics.

4- Intensive event report.

5- The spontaneous report in the case is the population of the single case report.

Coding of adverse events Adverse event coding is the process by which information from an AE reporter, called the "verbatim", is coded using standardized terminology from a medical coding dictionary, such as MedDRA. The purpose of medical coding is to convert adverse event information into terminology that can be readily identified and analyzed. For instance, Patient 1 may report that they had experienced "a very bad headache that felt like their head was being hit by a hammer" when taking Drug X. Or, Patient 2 may report that they had experienced a "slight, throbbing headache that occurred daily at about two in the afternoon" while taking Drug Y. Neither Verbatim 1 nor Verbatim 2 will exactly match a code in the MedDRA coding dictionary. However, both quotes describe different manifestations of a headache. As a result, in this example both quotes would be coded as PT Headache .

Seriousness determination Although somewhat intuitive, there are a set of criteria within pharmacovigilance that are used to distinguish a serious adverse event from a non-serious one. An adverse event is considered serious if it meets one or more of the following criteria: #results in death, or is life-threatening; #requires inpatient hospitalization or prolongation of existing hospitalization; #results in persistent or significant disability or incapacity; #results in a congenital anomaly; or #is otherwise "medically significant" Expedited reporting This refers to ICSRs that involve a serious and unlisted event that is considered related to the use of the drug. In most countries, the time frame for reporting expedited cases is 7/15 calendar days from the time a drug company receives notification of such a case. Within clinical trials such a case is referred to as a SUSAR. If the SUSAR involves an event that is life-threatening or fatal, it may be subject to a 7-day "clock". Cases that do not involve a serious, unlisted event may be subject to non-expedited or periodic reporting.

Clinical trial reporting Also known as AE or SAE reporting from clinical trials, safety information from clinical studies is used to establish a drug's safety profile in humans and is a key component that drug regulatory authorities consider in the decision-making as to whether to grant or deny market authorization for a drug. AE reporting occurs when study patients experience any kind of "untoward" event during the conducting of clinical trials. Non-serious adverse events are typically captured separately at a level lower than pharmacovigilance. AE and SAE information, which may also include relevant information from the patient's medical background, are reviewed and assessed for both causality and degree of seriousness by the study investigator. This information is forwarded to a sponsoring entity that is responsible for the reporting of this information, as appropriate, to drug regulatory authorities.

Spontaneous reporting Spontaneous reports are termed spontaneous as they take place during the clinician's normal diagnostic appraisal of a patient, when the clinician is drawing the conclusion that the drug may be implicated in the causality of the event.

Spontaneous reporting system relies on vigilant physicians and other healthcare professionals who not only generate a suspicion of an ADR, but also report it. It is an important source of regulatory actions such as taking a drug off the market or a label change due to safety problems.

Spontaneous reporting is the core data-generating system of international pharmacovigilance, relying on healthcare professionals to identify and report any adverse events to their national pharmacovigilance center, health authority, or to the drug manufacturer itself. Spontaneous reports are, by definition, submitted voluntarily although under certain circumstances these reports may be encouraged, or "stimulated", by media reports or articles published in medical or scientific publications, or by product lawsuits. In many parts of the world adverse event reports are submitted electronically using a defined message standard.

One of the major weaknesses of spontaneous reporting is that of under-reporting, where, unlike in clinical trials, less than 100% of those adverse events occurring are reported. Further complicating the assessment of adverse events, AE reporting behavior varies greatly between countries and in relation to the seriousness of the events, but in general probably less than 10% of all adverse events that occur are actually reported. The rule-of-thumb is that on a scale of 0 to 10, with 0 being least likely to be reported and 10 being the most likely to be reported, an uncomplicated non-serious event such as a mild headache will be closer to a "0" on this scale, whereas a life-threatening or fatal event will be closer to a "10" in terms of its likelihood of being reported. In view of this, medical personnel may not always see AE reporting as a priority, especially if the symptoms are not serious. And even if the symptoms are serious, the symptoms may not be recognized as a possible side effect of a particular drug or combination thereof. In addition, medical personnel may not feel compelled to report events that are viewed as expected. This is why reports from patients themselves are of high value. The confirmation of these events by a healthcare professional is typically considered to increase the value of these reports. Hence it is important not only for the patient to report the AE to his health care provider, but also report the AE to both the biopharmaceutical company and the FDA, EMA, ... This is especially important when one has obtained one's pharmaceutical from a compounding pharmacy.

As such, spontaneous reports are a crucial element in the worldwide enterprise of pharmacovigilance and form the core of the World Health Organization Database, which includes around 4.6 million reports, growing annually by about 250,000.

Aggregate reporting Aggregate reporting, also known as periodic reporting, plays a key role in the safety assessment of drugs. Aggregate reporting involves the compilation of safety data for a drug over a prolonged period of time, as opposed to single-case reporting which, by definition, involves only individual AE reports. The advantage of aggregate reporting is that it provides a broader view of the safety profile of a drug. Worldwide, the most important aggregate report is the Periodic Safety Update Report and Development Safety Update Report. This is a document that is submitted to drug regulatory agencies in Europe, the US and Japan, as well as other countries around the world. The PSUR was updated in 2012 and is now referred to in many countries as the Periodic Benefit Risk Evaluation report. As the title suggests, the PBRER's focus is on the benefit-risk profile of the drug, which includes a review of relevant safety data compiled for a drug product since its development.

Other reporting methods Some countries legally oblige spontaneous reporting by physicians. In most countries, manufacturers are required to submit, through its Qualified Person for Pharmacovigilance, all of the reports they receive from healthcare providers to the national authority. Others have intensive, focused programmes concentrating on new drugs, or on controversial drugs, or on the prescribing habits of groups of doctors, or involving pharmacists in reporting. All of these generate

potentially useful information. Such intensive schemes, however, tend to be the exception. A number of countries have reporting requirements or reporting systems specific to vaccine-related events.

Risk management Risk management is the discipline within pharmacovigilance that is responsible for signal detection and the monitoring of the risk-benefit profile of drugs. Other key activities within the area of risk management are that of the compilation of risk management plans and aggregate reports such as the Periodic Safety Update Report, Periodic Benefit-Risk Evaluation Report, and the Development Safety Update Report.

Causality assessment One of the most important, and challenging, problems in pharmacovigilance is that of the determination of causality.

Causality refers to the relationship of a given adverse event to a specific drug. Causality determination is often difficult because of the lack of clear-cut or reliable data. While one may assume that a positive temporal relationship might "prove" a positive causal relationship, this is not always the case. Indeed, a "bee sting" Adverse Event — where the AE can clearly be attributed to a specific causes — is by far the exception rather than the rule. This is due to the complexity of human physiology as well as that of disease and illnesses. By this reckoning, in order to determine causality between an adverse event and a drug, one must first exclude the possibility that there were other possible causes or contributing factors. If the patient is on a number of medications, it may be the combination of these drugs which causes the AE, and not any one individually. There have been a number of recent high-profile cases where the AE led to the death of an individual. The individual were not overdosed with any one of the many medications they were taking, but the combination there appeared to cause the AE. Hence it is important to include in your/one's AE report, not only the drug being reported, but also all other drugs the patient was also taking.

For instance, if a patient were to start Drug X and then three days later were to develop an AE, one might be tempted to attribute blame Drug X. However, before that can be done, the patient's medical history would need to be reviewed to look for possible risk factors for the AE. In other words, did the AE occur with the drug or because of the drug? This is because a patient on any drug may develop or be diagnosed with a condition that could not have possibly been caused by the drug. This is especially true for diseases, such as cancer, which develop over an extended period of time, being diagnosed in a patient who has been taken a drug for a relatively short period of time. On the other hand, certain adverse events, such as blood clots, can occur with certain drugs with only short-term exposure. Nevertheless, the determination of risk factors is an important step of confirming or ruling-out a causal relationship between an event and a drug.

Often the only way to confirm the existence of a causal relationship of an event to a drug is to conduct an observational study where the incidence of the event in a patient population taking the drug is compared to a control group. This may be necessary to determine if the background incidence of an event is less than that found in a group taking a drug. If the incidence of an event is statistically significantly higher in the "active" group versus the placebo group, it is possible that a causal relationship may exist to a drug, unless other confounding factors may exist.

Signal detection Signal detection involves a range of techniques. The WHO defines a safety signal as: "Reported information on a possible causal relationship between an adverse event and a drug, the relationship being unknown or incompletely documented previously". Usually more than a single report is required to generate a signal, depending upon the event and quality of the information available.

Data mining pharmacovigilance databases is one approach that has become increasingly popular with the availability of extensive data sources and inexpensive computing resources. The data sources may be owned by a pharmaceutical company, a drug regulatory authority, or a large healthcare provider. Individual Case Safety Reports in these databases are retrieved and converted into structured format, and statistical methods are applied to calculate statistical measures of association. If the statistical measure crosses an arbitrarily set threshold, a signal is declared for a given drug associated with a given adverse event. All signals deemed worthy of investigation, require further analysis using all available data in an attempt to confirm or refute the signal. If the analysis is inconclusive, additional data may be needed such as a post-marketing observational trial.

SD is an essential part of drug use and safety surveillance. Ideally, the goal of SD is to identify ADRs that were previously considered unexpected and to be able to provide guidance in the product's labeling as to how to minimize the risk of using the drug in a given patient population.

Risk management plans A risk management plan is a documented plan that describes the risks associated with the use of a drug and how they are being handled. The overall goal of an RMP is to assure a positive risk-benefit profile once the drug is marketed. The document is required to be submitted, in a specified format, with all new market authorization requests within the European Union. Although not necessarily required, RMPs may also be submitted in countries outside the EU. The risks described in an RMP fall into one of three categories: identified risks, potential risks, and unknown risks. Also described within an RMP are the measures that the Market Authorization Holder, usually a pharmaceutical company, will undertake to minimize the risks associated with the use of the drug. These measures are usually focused on the product's labeling and healthcare professionals. Indeed, the risks that are documented in a pre-authorization RMP will inevitably become part of the product's post-marketing labeling. Since a drug, once authorized, may be used in ways not originally studied in clinical trials, this potential "off-label use", and its associated risks, is also described within the RMP. RMPs can be very lengthy documents, running in some cases hundreds of pages and, in rare instances, up to a thousand pages long.

In the US, under certain circumstances, the FDA may require a company to submit a document called a Risk Evaluation and Mitigation Strategies for a drug that has a specific risk that FDA believes requires mitigation. While not as comprehensive as an RMP, a REMS can require a sponsor to perform certain activities or to follow a protocol, referred to as Elements to Assure Safe Use, to assure that a positive risk-benefit profile for the drug is maintained for the circumstances under which the product is marketed.

Risk/benefit profile of drugs Pharmaceutical companies are required by law in most countries to perform clinical trials, testing new drugs on people before they are made generally available. This occurs after a drug has been pre-screened for toxicity, sometimes using animals for testing. The manufacturers or their agents usually select a representative sample of patients for whom the drug is designed – at most a few thousand – along with a comparable control group. The control group may receive a placebo and/or another drug, often a so-called "gold standard" that is "best" drug marketed for the disease.

The purpose of clinical trials is to determine: if a drug works and how well it works if it has any harmful effects, and if it does more good than harm, and how much more? If it has a potential for harm, how probable and how serious is the harm?

Clinical trials do, in general, tell a good deal about how well a drug works. They provide information that should be reliable for larger populations with the same characteristics as the trial group – age, gender, state of health, ethnic origin, and so on though target clinical populations are typically very different from trial populations with respect to such characteristics.

The variables in a clinical trial are specified and controlled, but a clinical trial can never tell you the whole story of the effects of a drug in all situations. In fact, nothing could tell you the whole story, but a clinical trial must tell you enough; "enough" being determined by legislation and by contemporary judgments about the acceptable balance of benefit and harm. Ultimately, when a drug is marketed it may be used in patient populations that were not studied during clinical trials and a different set of warnings, precautions or contraindications for the product's labeling may be necessary in order to maintain a positive risk/benefit profile in all known populations using the drug.

Pharmacoepidemiology Pharmacoepidemiology is the study of the incidence of adverse drug reactions in patient populations using drug agents.

Pharmacokinetics and pharmacogenomics Although often used interchangeably, there are subtle differences between the two disciplines. Pharmacokinetics is generally regarded as the study or clinical testing of genetic variation that gives rise to differing responses to drugs, including adverse drug reactions. It is hoped that pharmacokinetics will eventually provide information as to which genetic profiles in patients will place those patients at greatest risk, or provide the greatest benefit, for using a particular drug or drugs. Pharmacogenomics, on the other hand, is the broader application of genomic technologies to new drug discovery and further characterization of older drugs.

International collaboration The following organizations play a key collaborative role in the global oversight of pharmacovigilance.

The World Health Organization The principle of international collaboration in the field of pharmacovigilance is the basis for the WHO Programme for International Drug Monitoring, through which over 150 member nations have systems in place that encourage healthcare personnel to record and report adverse effects of drugs in their patients. These reports are assessed locally and may lead to action within the country. Since 1978, the programme has been managed by the Uppsala Monitoring Centre to which member countries send their reports to be processed, evaluated and entered into an international database called VigiBase. Membership in the WHO Programme enables a country to know if similar reports are being made elsewhere. When there are several reports of adverse reactions to a particular drug, this process may lead to the detection of a signal, and an alert about a possible hazard communicated to members countries after detailed evaluation and expert review on the biological stasis and homeostasis of the body.

Clb12/2020001 The International Council for Harmonization The ICH is a global organization with members from the European Union, the United States and Japan; its goal is to recommend global standards for drug companies and drug regulatory authorities around the world, with the ICH Steering Committee overseeing harmonization activities.https://247meeting.com/blog/steering-committee/ Established in 1990, each of its six co-sponsors—the EU, the European Federation of Pharmaceutical Industries and Associations, Japan's Ministry of Health, Labor and Welfare, the Japanese Pharmaceutical Manufacturers Association, the U.S. Food

and Drug Administration, and the Pharmaceutical Research and Manufacturers of America —have two seats on the SC. Other parties have a significant interest in ICH and have been invited to nominate Observers to the SC; three current observers are the WHO, Health Canada, and the European Free Trade Association, with the International Federation of Pharmaceutical Manufacturers Association participating as a non-voting member of the SC. The Council for International Organizations of Medical Science The CIOMS, a part of the WHO, is globally oriented think tank that provides guidance on drug safety related topics through its Working Groups. The CIOMS prepares reports that are used as a reference for developing future drug regulatory policy and procedures, and over the years, many of CIOMS' proposed policies have been adopted. Examples of topics these reports have covered include: Current Challenges in Pharmacovigilance: Pragmatic Approaches ; Management of Safety Information from Clinical Trials ; the Development Safety Update Report : Harmonizing the Format and Content for Periodic Safety Reporting During Clinical Trials ; and Practical Aspects of Signal Detection in Pharmacovigilance: Report of CIOMS Working Group .

The International Society of Pharmacovigilance The I Sop is an international non-profit scientific organization, which aims to foster pharmacovigilance both scientifically and educationally, and enhance all aspects of the safe and proper use of medicines, in all countries. It was established in 1992 as the European Society of Pharmacovigilance.

Society of Pharmacovigilance, India, also established in 1992, is partner member of I Sop. Local societies include the Boston Society of Pharmacovigilance Physicians.

Regulatory authorities Drug regulatory authorities play a key role in national or regional oversight of pharmacovigilance. Some of the agencies involved are listed below.

United States In the U.S., with about a third of all global 2011 pharmaceutical expenditures, As JE Sack man notes, as of April 2013 "there is no Latin American equivalent of the European Medicines Agency—no common body with the power to facilitate greater consistency across countries". For simplicity, and per sources, 17 smaller economies are discussed alongside the 4 pharm emerging large economies of Argentina, Brazil, Mexico and Venezuela—Bolivia, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Nicaragua, Panama, Paraguay, Peru, Suriname, and Uruguay. As of June 2012, 16 of this total of 21 countries have systems for immediate reporting and 9 have systems for periodic reporting of adverse events for on-market agents, while 10 and 8, respectively, have systems for immediate and periodic reporting of adverse events during clinical trials; most of these have PV requirements that rank as "high or medium...in line with international standards”. The WHO's Pan American Network for Drug Regulatory Harmonization seeks to assist Latin American countries in develops harmonized PV regulations. Scientists working on pharmacovigilance share their experiences, findings, innovative ideas and researches during the annual meeting of Society of Pharmacovigilance, India. In Egypt, PV is regulated by the Egyptian Pharmacovigilance Center of the Egyptian Ministry of Health.

European Union The EU5 accrued ~17% of global 2011 pharmaceutical expenditures. The EMA requires the individual marketing authorization holders to submit all received adverse reactions in electronic form, except in exceptional circumstances;

the reporting obligations of the various stakeholders are defined by EEC legislation, namely Regulation No 726/2004, and for human medicines, European Union Directive 2001/83/EC as amended and Directive 2001/20/EC. In 2002, Heads of Medicines Agencies agreed on a mandate for an ad hoc Working Group on establishing a European risk management strategy; the Working Group considered the conduct of a high level survey of EU pharmacovigilance resources to promote the utilization of expertise and encourage collaborative working.

In conjunction with this oversight, individual countries maintain their distinct regulatory agencies with PV responsibility.

For instance, in Spain, PV is regulated by the Agencia Española de Medicamentos y Productos Sanitarios, a legal entity that retains the right to suspend or withdraw the authorization of pharmaceuticals already on-market if the evidence shows that safety of an agent are unsatisfactory.

Rest of Europe, including non-EU The remaining EU and non-EU countries outside the EU5 accrued ~7% of global 2011 pharmaceutical expenditures.

Japan In Japan, with ~12% of all global 2011 pharmaceutical expenditures, Canada was second, following the United States, in holding the highest total prescription drug expenditures per capita in 2011 at around 750 US dollars per person. Canada also pays such a large amount for pharmaceuticals that it was second, next to Switzerland, for the amount of money spent for a certain amount of prescription drugs . It was also accessed that Canada was one of the top countries that increased its yearly average per capita growth on pharmaceutical expenditures the most from 2000-2010 with 4 percent a year The MHPD mainly collects adverse drug reaction reports through a network of reporting centers to analyze and issue possible warnings to the public, and currently utilizes newsletters, advisories, adverse reaction centers, as well as electronic mailing lists. However, it does not currently maintain a database or list of drugs removed from Canada as a result of safety concerns.

In August 2017, there was a government controversy in which a bill, known as “Vanessa’s Law”, to protect patients from potentially dangerous prescription drugs was not being fully realized by hospitals; Health Canada only required hospitals to report “unexpected” negative reactions to prescription drugs, rather than any and all adverse reactions, with the justification of managing “administrative overload”.

South Korea The Republic of Korea, with ~1% of all global 2011 pharmaceutical expenditures, The Pharmacovigilance activities in Kenya are supported by the School of Pharmacy, University of Nairobi through its Master of Pharmacy in Pharmacoepidemiology & Pharmacovigilance program offered by the Department of Pharmacology and Pharmacognosy.

In Uganda, PV is regulated by the National Drug Authority.

Rest of world ROW accrued ~7% of global 2011 pharmaceutical expenditures. A concept combining pharmacovigilance and environmental pharmacology, intended to focus attention on this area, was introduced first as pharmacoenvironmentology in 2006 by Syed Ziaur Rahman and later as ecopharmacology with further concurrent and later terms for the same concept.

The first of these routes to the environment, elimination through living organisms subsequent to pharmacotherapy, is suggested as the principal source of environmental contamination, and EPV is intended to deal specifically with this impact of pharmacological agents on the environment.

Activities of EPV have been suggested to include: Increasing, generally, the availability of environmental data on medicinal products; Tracking emerging data on environmental exposure, effects and risks after product launch; Using Environmental Risk Management Plans to manage risk throughout a drug's life cycle; Following risk identification, promoting further research and environmental monitoring, and In general, promoting a global perspective on EPV issues.

Given the inherent difference between medicinal products and medical products, the vigilance of medical devices is also different from that of medicinal products. To reflect this difference, a classification system has been adopted in some countries to stratify the risk of failure with the different classes of devices. The classes of devices typically run on a 1-3 or 1-4 scale, with Class 1 being the least likely to cause significant harm with device failure versus Classes 3 or 4 being the most likely to cause significant harm with device failure. An example of a device in the "low risk" category would be contact lenses. An example of a device in the "high risk" category would be cardiac pacemakers.

Medical device reporting, which is the reporting of adverse events with medical devices, is similar to that with medicinal products, although there are differences. In contrast to reporting of medical products reports of side-effects play only a minor role with most medical devices. The vast majority of the medical device reports are related to medical device defects or failures. Other notable differences are in the obligations to report by other actors that aren't manufacturers, in the US user-facilities such as hospitals and nursing homes are legally required to report suspected medical devicerelated deaths to both FDA and the manufacturer, if known, and serious injuries to the manufacturer or to FDA, if the manufacturer is unknown. This is in contrast to the voluntary reporting of AEs with medicinal products. Similar obligations exist in multiple European countries. The European regulation on medical devices and the European regulation on in vitro diagnostic medical devices obliges other economic operators most notably importers and distributors to inform manufacturers, and in certain instances the authorities, of incidents and safety issues with medical devices that they have distributed or imported in the European market.

For herbal medicines The safety of herbal medicines has become a major concern to both national health authorities and the general public.

The use of herbs as traditional medicines continues to expand rapidly across the world; many people now take herbal medicines or herbal products for their health care in different national health-care settings. However, mass media reports of adverse events with herbal medicines can be incomplete and therefore misleading. Moreover, it can be difficult to identify the causes of herbal medicine-associated adverse events since the amount of data on each event is generally less than for pharmaceuticals formally regulated as drugs .

Novel sources With the emergence of advanced artificial intelligence methods and social media big data, researchers are now using publicly posted social media data to discover unknown side effects of prescription medications. Natural language processing and machine learning methods are developed and used for identifying non-standard expressions of side effects.

Industry associations Boston Society of Pharmacovigilance Physicians.

See also Adverse drug reaction Adverse effect Boston Collaborative Drug Surveillance Program Consultant pharmacist COSTART – Coding Symbols for a Thesaurus of Adverse Reaction Terms Drug Logic European Medicines Agency EudraVigilance Food and Drug Administration International Society for Pharmacoepidemiology International Society of Pharmacovigilance List of withdrawn drugs Society of Pharmacovigilance, India MedDRA – Medical Dictionary for Regulatory Activities Medical device Med Watch National Drug & Safety League Public health Pharmacoepidemiology Pharmacotherapy Pharmacokinetics Pharmacogenomics Pharmaceuticals and personal care products in the environment Post-market surveillance Proportional reporting ratio Uppsala Monitoring Centre WHOART.

PsychiatryPsychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of mental disorders. These include various maladaptations related to mood, behaviour, cognition, and perceptions. See glossary of psychiatry.

Initial psychiatric assessment of a person typically begins with a case history and mental status examination. Physical examinations and psychological tests may be conducted. On occasion, neuroimaging or other neurophysiological techniques are used.

The combined treatment of psychiatric medication and psychotherapy has become the most common mode of psychiatric treatment in current practice, but contemporary practice also includes a wide variety of other modalities, e.g., assertive community treatment, community reinforcement, and supported employment. Treatment may be delivered on an inpatient or outpatient basis, depending on the severity of functional impairment or on other aspects of the disorder in question. An inpatient may be treated in a psychiatric hospital. Research and treatment within psychiatry as a whole are conducted on an interdisciplinary basis with other professionals, such as epidemiologists, nurses, social workers, occupational therapists or clinical psychologists.

Etymology The term psychiatry was first coined by the German physician Johann Christian Reil in 1808 and literally means the 'medical treatment of the soul' . A medical doctor specializing in psychiatry is a psychiatrist.

Theory and focus Psychiatry refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans. It has been described as an intermediary between the world from a social context and the world from the perspective of those who are mentally ill.

People who specialize in psychiatry often differ from most other mental health professionals and physicians in that they must be familiar with both the social and biological sciences. it has generally been considered a middle ground between neurology and psychology. Because psychiatry and neurology are deeply intertwined medical specialties, all certification for both specialties and for their subspecialties is offered by a single board, the American Board of Psychiatry and Neurology, one of the member boards of the American Board of Medical Specialties. Unlike other physicians and neurologists, psychiatrists specialize in the doctor–patient relationship and are trained to varying extents in the use of psychotherapy and other therapeutic communication techniques. Psychiatrists also differ from psychologists in that they are physicians and have post-graduate training called residency in psychiatry; the quality and thoroughness of their graduate medical training is identical to that of all other physicians. Psychiatrists can therefore counsel patients, prescribe medication, order laboratory tests, order neuroimaging, and conduct physical examinations.

Ethics The World Psychiatric Association issues an ethical code to govern the conduct of psychiatrists. The psychiatric code of ethics, first set forth through the Declaration of Hawaii in 1977 has been expanded through a 1983 Vienna update and in the broader Madrid Declaration in 1996. The code was further revised during the organization's general assemblies in 1999, 2002, 2005, and 2011.

The World Psychiatric Association code covers such matters as confidentiality, the death penalty, ethnic or cultural discrimination, torture, and up-to-date knowledge.

In establishing such ethical codes, the profession has responded to a number of controversies about the practice of psychiatry, for example, surrounding the use of lobotomy and electroconvulsive therapy.

Discredited psychiatrists who operated outside the norms of medical ethics include Harry Bailey, Donald Ewen Cameron, Samuel A. Cartwright, Henry Cotton, and Andrei Snezhnevsky.

Approaches Psychiatric illnesses can be conceptualised in a number of different ways. The biomedical approach examines signs and symptoms and compares them with diagnostic criteria. Mental illness can be assessed, conversely, through a narrative which tries to incorporate symptoms into a meaningful life history and to frame them as responses to external conditions. Both approaches are important in the field of psychiatry but have not sufficiently reconciled to settle controversy over either the selection of a psychiatric paradigm or the specification of psychopathology. The notion of a "biopsychosocial model" is often used to underline the multifactorial nature of clinical impairment. In this notion the word model is not used in a strictly scientific way though. Behaviorism is a therapeutic school of thought that elects to focus solely on real and observable events, rather than mining the unconscious or subconscious. Psychoanalysis, on the other hand, concentrates its dealings on early childhood, irrational drives, the unconscious, and conflict between conscious and unconscious streams.

Practitioners All physicians can diagnose mental disorders and prescribe treatments utilizing principles of psychiatry. Psychiatrists are trained physicians who specialize in psychiatry and are certified to treat mental illness. They may treat outpatients, inpatients, or both; they may practice as solo practitioners or as members of groups; they may be self-employed, be members of partnerships, or be employees of governmental, academic, nonprofit, or for-profit entities; employees of hospitals; they may treat military personnel as civilians or as members of the military; and in any of these settings they may function as clinicians, researchers, teachers, or some combination of these. Although psychiatrists may also go through significant training to conduct psychotherapy, psychoanalysis or cognitive behavioral therapy, it is their training as physicians that differentiates them from other mental health professionals.

As a career choice Psychiatry was not a popular career choice among medical students, even though medical school placements are rated favorably. This has resulted in a significant shortage of psychiatrists in the United States and elsewhere. Strategies to address this shortfall have included the use of short 'taster' placements early in the medical school curriculum Recently, however, there has been an increase in the number of medical students entering into a psychiatry residency. There are several reasons for this surge including the interesting nature of the field, growing interest in genetic biomarkers involved in psychiatric diagnoses, and newer pharmaceuticals on the drug market to treat psychiatric illnesses.

Subspecialties The field of psychiatry has many subspecialties that require additional training and certification by the American Board of Psychiatry and Neurology. Such subspecialties include: Addiction psychiatry Brain Injury Medicine Child and adolescent psychiatry Clinical neurophysiology

Consultation-liaison psychiatry, also known as psychosomatic medicine Epilepsy Forensic psychiatry Geriatric psychiatry Hospice and palliative medicine Pain medicine Sleep medicine Additional psychiatry subspecialties, for which ABPN does not provide formal certification, include: Biological psychiatry Cognition diseases as in various forms of dementia Community psychiatry Cross-cultural psychiatry Emergency psychiatry Global Mental Health Learning disabilities Military psychiatry Neurodevelopmental disorders Neuropsychiatry Social psychiatry Addiction psychiatry focuses on evaluation and treatment of individuals with alcohol, drug, or other substance-related disorders, and of individuals with dual diagnosis of substance-related and other psychiatric disorders. Biological psychiatry is an approach to psychiatry that aims to understand mental disorders in terms of the biological function of the nervous system. Child and adolescent psychiatry is the branch of psychiatry that specializes in work with children, teenagers, and their families. Community psychiatry is an approach that reflects an inclusive public health perspective and is practiced in community mental health services. Cross-cultural psychiatry is a branch of psychiatry concerned with the cultural and ethnic context of mental disorder and psychiatric services. Emergency psychiatry is the clinical application of psychiatry in emergency settings. Forensic psychiatry utilizes medical science generally, and psychiatric knowledge and assessment methods in particular, to help answer legal questions. Geriatric psychiatry is a branch of psychiatry dealing with the study, prevention, and treatment of mental disorders in the elderly. Global Mental Health is an area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide, although some scholars consider it to be a neo-colonial, culturally insensitive project.

Liaison psychiatry is the branch of psychiatry that specializes in the interface between other medical specialties and psychiatry. Military psychiatry covers special aspects of psychiatry and mental disorders within the military context.

Neuropsychiatry is a branch of medicine dealing with mental disorders attributable to diseases of the nervous system.

Social psychiatry is a branch of psychiatry that focuses on the interpersonal and cultural context of mental disorder and mental well-being.

In larger healthcare organizations, psychiatrists often serve in senior management roles, where they are responsible for the efficient and effective delivery of mental health services for the organization's constituents. For example, the Chief of Mental Health Services at most VA medical centers is usually a psychiatrist, although psychologists occasionally are selected for the position as well.

In the United States, psychiatry is one of the few specialties which qualify for further education and board-certification in pain medicine, palliative medicine, and sleep medicine.

Research Psychiatric research is, by its very nature, interdisciplinary; combining social, biological and psychological perspectives in attempt to understand the nature and treatment of mental disorders. Clinical and research psychiatrists study basic and clinical psychiatric topics at research institutions and publish articles in journals. Under the supervision of institutional review boards, psychiatric clinical researchers look at topics such as neuroimaging, genetics, and psychopharmacology in order to enhance diagnostic validity and reliability, to discover new treatment methods, and to classify new mental disorders.

Clinical application Diagnostic systems Psychiatric diagnoses take place in a wide variety of settings and are performed by many different health professionals.

Therefore, the diagnostic procedure may vary greatly based upon these factors. Typically, though, a psychiatric diagnosis utilizes a differential diagnosis procedure where a mental status examination and physical examination is conducted, with pathological, psychopathological or psychosocial histories obtained, and sometimes neuroimages or other neurophysiological measurements are taken, or personality tests or cognitive tests administered. In some cases, a brain scan might be used to rule out other medical illnesses, but at this time relying on brain scans alone cannot accurately diagnose a mental illness or tell the risk of getting a mental illness in the future. Some clinicians are beginning to utilize genetics and speech during the diagnostic process but on the whole these remain research topics.

Diagnostic manuals Three main diagnostic manuals used to classify mental health conditions are in use today. The ICD-10 is produced and published by the World Health Organization, includes a section on psychiatric conditions, and is used worldwide. The Diagnostic and Statistical Manual of Mental Disorders, produced and published by the American Psychiatric Association, is primarily focused on mental health conditions and is the main classification tool in the United States. It is currently in its fifth revised edition and is also used worldwide.

The stated intention of diagnostic manuals is typically to develop replicable and clinically useful categories and criteria, to facilitate consensus and agreed upon standards, whilst being a theoretical as regards etiology. However, the categories are nevertheless based on particular psychiatric theories and data; they are broad and often specified by numerous possible combinations of symptoms, and many of the categories overlap in symptomology or typically occur together. While originally intended only as a guide for experienced clinicians trained in its use, the nomenclature is now widely used by clinicians, administrators and insurance companies in many countries.

The DSM has attracted praise for standardizing psychiatric diagnostic categories and criteria. It has also attracted controversy and criticism. Some critics argue that the DSM represents an unscientific system that enshrines the opinions

of a few powerful psychiatrists. There are ongoing issues concerning the validity and reliability of the diagnostic categories; the reliance on superficial symptoms; the use of artificial dividing lines between categories and from 'normality'; possible cultural bias; medicalization of human distress and financial conflicts of interest, including with the practice of psychiatrists and with the pharmaceutical industry; political controversies about the inclusion or exclusion of diagnoses from the manual, in general or in regard to specific issues; and the experience of those who are most directly affected by the manual by being diagnosed, including the consumer/survivor movement. The publication of the DSM, with tightly guarded copyrights, now makes APA over $5 million a year, historically adding up to over $100 million.

Treatment General considerations Individuals with mental health conditions are commonly referred to as patients but may also be called clients, consumers, or service recipients. They may come under the care of a psychiatric physician or other psychiatric practitioners by various paths, the two most common being self-referral or referral by a primary care physician.

Alternatively, a person may be referred by hospital medical staff, by court order, involuntary commitment, or, in the UK and Australia, by sectioning under a mental health law.

Persons who undergo a psychiatric assessment are evaluated by a psychiatrist for their mental and physical condition.

This usually involves interviewing the person and often obtaining information from other sources such as other health and social care professionals, relatives, associates, law enforcement personnel, emergency medical personnel, and psychiatric rating scales. A mental status examination is carried out, and a physical examination is usually performed to establish or exclude other illnesses that may be contributing to the alleged psychiatric problems. A physical examination may also serve to identify any signs of self-harm; this examination is often performed by someone other than the psychiatrist, especially if blood tests and medical imaging are performed.

Like most medications, psychiatric medications can cause adverse effects in patients, and some require ongoing therapeutic drug monitoring, for instance full blood counts serum drug levels, renal function, liver function or thyroid function. Electroconvulsive therapy is sometimes administered for serious and disabling conditions, such as those unresponsive to medication. The efficacy and adverse effects of psychiatric drugs may vary from patient to patient.

For many years, controversy has surrounded the use of involuntary treatment and use of the term "lack of insight" in describing patients. Mental health laws vary significantly among jurisdictions, but in many cases, involuntary psychiatric treatment is permitted when there is deemed to be a risk to the patient or others due to the patient's illness.

Involuntary treatment refers to treatment that occurs based on the treating physician's recommendations without requiring consent from the patient.

Mental health issues such as mood disorders and schizophrenia and other psychotic disorders were the most common principle diagnoses for Medicaid super-utilizers in the United States in 2012.

Inpatient treatment Psychiatric treatments have changed over the past several decades. In the past, psychiatric patients were often hospitalized for six months or more, with some cases involving hospitalization for many years.

Average inpatient psychiatric treatment stay has decreased significantly since the 1960s, a trend known as deinstitutionalization. Today in most countries, people receiving psychiatric treatment are more likely to be seen as outpatients. If hospitalization is required, the average hospital stay is around one to two weeks, with only a small

number receiving long-term hospitalization.. However, in Japan psychiatric hospitals continue to keep patients for long periods, sometimes even keeping them in physical restraints, strapped to their beds for periods of weeks or months.

Psychiatric inpatients are people admitted to a hospital or clinic to receive psychiatric care. Some are admitted involuntarily, perhaps committed to a secure hospital or in some jurisdictions to a facility within the prison system. In many countries including the United States and Canada, the criteria for involuntary admission vary with local jurisdiction. They may be as broad as having a mental health condition, or as narrow as being an immediate danger to themselves or others. Bed availability is often the real determinant of admission decisions to hard pressed public facilities. European Human Rights legislation restricts detention to medically certified cases of mental disorder, and adds a right to timely judicial review of detention.

People may be admitted voluntarily if the treating doctor considers that safety isn't compromised by this less restrictive option. Inpatient psychiatric wards may be secure or unlocked/open. Some wards are mixed-sex whilst same-sex wards are increasingly favored to protect women inpatients. Once in the care of a hospital, people are assessed, monitored, and often given medication and care from a multidisciplinary team, which may include physicians, pharmacists, psychiatric nurse practitioners, psychiatric nurses, clinical psychologists, psychotherapists, psychiatric social workers, occupational therapists and social workers. If a person receiving treatment in a psychiatric hospital is assessed as at particular risk of harming themselves or others, they may be put on constant or intermittent one-to-one supervision and may be put in physical restraints or medicated. People on inpatient wards may be allowed leave for periods of time, either accompanied or on their own.

In many developed countries there has been a massive reduction in psychiatric beds since the mid-20th century, with the growth of community care. Standards of inpatient care remain a challenge in some public and private facilities, due to levels of funding, and facilities in developing countries are typically grossly inadequate for the same reason. Even in developed countries, programs in public hospitals vary widely. Some may offer structured activities and therapies offered from many perspectives while others may only have the funding for medicating and monitoring patients. This may be problematic in that the maximum amount of therapeutic work might not actually take place in the hospital setting. This is why hospitals are increasingly used in limited situations and moments of crisis where patients are a direct threat to themselves or others. Alternatives to psychiatric hospitals that may actively offer more therapeutic approaches include rehabilitation centers or "rehab" as popularly termed.

Outpatient treatment Outpatient treatment involves periodic visits to a psychiatrist for consultation in his or her office, or at a communitybased outpatient clinic. Initial appointments, at which the psychiatrist conducts a psychiatric assessment or evaluation of the patient, are typically 45 to 75 minutes in length. Follow-up appointments are generally shorter in duration, i.e., 15 to 30 minutes, with a focus on making medication adjustments, reviewing potential medication interactions, considering the impact of other medical disorders on the patient's mental and emotional functioning, and counseling patients regarding changes they might make to facilitate healing and remission of symptoms . The frequency with which a psychiatrist sees people in treatment varies widely, from once a week to twice a year, depending on the type, severity and stability of each person's condition and depending on what the clinician and patient decide would be best.

Increasingly, psychiatrists are limiting their practices to psychopharmacology, as opposed to previous practice in which a psychiatrist would provide traditional 50-minute psychotherapy sessions, of which psychopharmacology would be a part, but most of the consultation sessions consisted of "talk therapy." This shift began in the early 1980s and accelerated in the 1990s and 2000s. A major reason for this change was the advent of managed care insurance plans, which began to limit reimbursement for psychotherapy sessions provided by psychiatrists. The underlying assumption was that psychopharmacology was at least as effective as psychotherapy, and it could be delivered more efficiently

because less time is required for the appointment. For example, most psychiatrists schedule three or four follow-up appointments per hour, as opposed to seeing one patient per hour in the traditional psychotherapy model. Because of this shift in practice patterns, psychiatrists often refer patients whom they think would benefit from psychotherapy to other mental health professionals, e.g., clinical social workers and psychologists.

History The earliest known texts on mental disorders are from ancient India and include the Ayurvedic text, Charaka Samhita.

The first hospitals for curing mental illness were established in India during the 3rd century BCE. The Greeks also created early manuscripts about mental disorders. In the 4th century BCE, Hippocrates theorized that physiological abnormalities may be the root of mental disorders. During the 5th century BCE, mental disorders, especially those with psychotic traits, were considered supernatural in origin, a view which existed throughout ancient Greece and Rome, Religious leaders often turned to versions of exorcism to treat mental disorders often utilizing methods that many consider to be cruel or barbaric methods. Trepanning was one of these methods used throughout history. As chief physician of a hospital in Baghdad, he was also the director of one of the first psychiatric wards in the world. Two of his works in particular, El-Mansuri and Al-Hawi, provide descriptions and treatments for mental illnesses.

The first bimaristan was founded in Baghdad in the 9th century, and several others of increasing complexity were created throughout the Arab world in the following centuries. Some of the bimaristans contained wards dedicated to the care of mentally ill patients, most of whom suffered from debilitating illnesses or exhibited violence. Specialist hospitals such as Bethlem Royal Hospital in London were built in medieval Europe from the 13th century to treat mental disorders, but were used only as custodial institutions and did not provide any type of treatment.

The beginning of psychiatry as a medical specialty is dated to the middle of the nineteenth century, although its germination can be traced to the late eighteenth century. In the late 17th century, privately run asylums for the insane began to proliferate and expand in size. In 1713 the Bethel Hospital Norwich was opened, the first purpose-built asylum in England. In 1656, Louis XIV of France created a public system of hospitals for those suffering from mental disorders, but as in England, no real treatment was applied.

During the Enlightenment attitudes towards the mentally ill began to change. It came to be viewed as a disorder that required compassionate treatment. In 1758 English physician William Battie wrote his Treatise on Madness on the management of mental disorder. It was a critique aimed particularly at the Bethlem Hospital, where a conservative regime continued to use barbaric custodial treatment. Battie argued for a tailored management of patients entailing cleanliness, good food, fresh air, and distraction from friends and family. He argued that mental disorder originated from dysfunction of the material brain and body rather than the internal workings of the mind.

The introduction of moral treatment was initiated independently by the French doctor Philippe Pinel and the English Quaker William Tuke.

Although Tuke, Pinel and others had tried to do away with physical restraint, it remained widespread into the 19th century. At the Lincoln Asylum in England, Robert Gardiner Hill, with the support of Edward Parker Charlesworth, pioneered a mode of treatment that suited "all types" of patients, so that mechanical restraints and coercion could be dispensed with — a situation he finally achieved in 1838. In 1839 Sergeant John Adams and Dr. John Conolly were impressed by the work of Hill, and introduced the method into their Hanwell Asylum, by then the largest in the country.

The modern era of institutionalized provision for the care of the mentally ill, began in the early 19th century with a large state-led effort. In England, the Lunacy Act 1845 was an important landmark in the treatment of the mentally ill, as it explicitly changed the status of mentally ill people to patients who required treatment. All asylums were required to

have written regulations and to have a resident qualified physician. In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country.

In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. The Utica State Hospital was opened around 1850. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect.

At the turn of the century, England and France combined had only a few hundred individuals in asylums. By the late 1890s and early 1900s, this number had risen to the hundreds of thousands. However, the idea that mental illness could be ameliorated through institutionalization ran into difficulties. Psychiatrists were pressured by an ever-increasing patient population, In the early 1800s, psychiatry made advances in the diagnosis of mental illness by broadening the category of mental disease to include mood disorders, in addition to disease level delusion or irrationality. The 20th century introduced a new psychiatry into the world, with different perspectives of looking at mental disorders. For Emil Kraepelin, the initial ideas behind biological psychiatry, stating that the different mental disorders are all biological in nature, evolved into a new concept of "nerves", and psychiatry became a rough approximation of neurology and neuropsychiatry. Following Sigmund Freud's pioneering work, ideas stemming from psychoanalytic theory also began to take root in psychiatry. The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of warehoused in asylums. as did lithium carbonate's ability to stabilize mood highs and lows in bipolar disorder in 1948. Psychotherapy was still utilized, but as a treatment for psychosocial issues. This proved the idea of neurochemical nature of many psychiatric disorders.

Another approach to look for biomarkers of psychiatric disorders is Neuroimaging that was first utilized as a tool for psychiatry in the 1980s.

In 1963, US president John F. Kennedy introduced legislation delegating the National Institute of Mental Health to administer Community Mental Health Centers for those being discharged from state psychiatric hospitals. Later, though, the Community Mental Health Centers focus shifted to providing psychotherapy for those suffering from acute but less serious mental disorders. Critique of psychiatry from within the field comes from the critical psychiatry group in the UK. The term "anti-psychiatry" was coined by psychiatrist David Cooper in 1967 and was later made popular by Thomas Szasz. The word "Antipsychiatrie" was already used in Germany in 1904. The basic premise of the anti-psychiatry movement is that psychiatrists attempt to classify "normal" people as "deviant;" psychiatric treatments are ultimately more damaging than helpful to patients; and psychiatry's history involves dangerous treatments, such as the frontal lobectomy. Several former patient groups have been formed often referring to themselves as "survivors." In 1973, the Rosenhan experiment was conducted to determine the validity of psychiatric diagnosis. Volunteers feigned hallucinations to enter psychiatric hospitals, and acted normally afterwards. They were diagnosed with psychiatric disorders and were given antipsychotic drugs. The study was conducted by psychologist David Rosenhan, a Stanford University professor, and published by the journal Science under the title "On being sane in insane places". However, the neutrality of the project is nowadays often questioned and the project itself is seen by many experts as manipulated.

The Church of Scientology is critical of psychiatry, whereas others have questioned the veracity of information the Church of Scientology provides to the public.

See also Psychiatrist Medical psychology

Biopsychiatry controversy Child and adolescent psychiatry Telepsychiatry Bullying in psychiatry Psychiatry organizations Psychiatry Innovation Lab Notes References Citations Cited texts Further reading Francis, Gavin, "Changing Psychiatry's Mind", The New York Review of Books, vol. LXVIII, no. 1, pp. 26–29. "Ental disorders are different .... To treat them as purely physical is to misunderstand their nature." "are based on distress and need rather than diagnos", which is often uncertain, erratic, and unreplicable.

Veterinary scienceVeterinary medicine is the branch of medicine that deals with the prevention, control, diagnosis, and treatment of disease, disorder, and injury in animals. Along with this, it deals with animal rearing, husbandry, breeding, research on nutrition, and product development. The scope of veterinary medicine is wide, covering all animal species, both domesticated and wild, with a wide range of conditions that can affect different species.

Veterinary medicine is widely practiced, both with and without professional supervision. Professional care is most often led by a veterinary physician, but also by paraveterinary workers, such as veterinary nurses or technicians. This can be augmented by other paraprofessionals with specific specialties, such as animal physiotherapy or dentistry, and speciesrelevant roles such as farriers.

Veterinary science helps human health through the monitoring and control of zoonotic disease, food safety, and indirectly through human applications from basic medical research. They also help to maintain food supply through livestock health monitoring and treatment, and mental health by keeping pets healthy and long-living. Veterinary scientists often collaborate with epidemiologists and other health or natural scientists, depending on type of work.

Ethically, veterinarians are usually obliged to look after animal welfare. Veterinarians diagnose, treat, and help keep animals safe and healthy.

History Premodern era Archeological evidence, in the form of a cow skull upon which trepanation had been performed, shows that people were performing veterinary procedures in the Neolithic.

The Egyptian Papyrus of Kahun is the first extant record of veterinary medicine.

The Shalihotra Samhita, dating from the time of Ashoka, is an early Indian veterinary treatise. The edicts of Asoka read: "Everywhere King Piyadasi made two kinds of medicine available, medicine for people, and medicine for animals.

Where no healing herbs for people and animals were available, he ordered that they be bought and planted."

Hippiatrica is a Byzantine compilation of hippiatrics, dated to the fifth or sixthth century AD. The first attempts to organize and regulate the practice of treating animals tended to focus on horses because of their economic significance. In the middle Ages, farriers combined their work in horseshoeing with the more general task of "horse doctoring".

The Arabic tradition of Bayṭara, or Shiyāt al-Khayl, originates with the treatise of Ibn Akhī Hizām.

In 1356, the Lord Mayor of London, concerned at the poor standard of care given to horses in the city, requested that all farriers operating within a 7-mile radius of the City of London form a "fellowship" to regulate and improve their practices. This ultimately led to the establishment of the Worshipful Company of Farriers in 1674.

Meanwhile, Carlo Ruini's book Anatomia Del Cavallo was published in 1598. It was the first comprehensive treatise on the anatomy of a nonhuman species.

Establishment of profession

The first veterinary school was founded in Lyon, France, in 1762 by Claude Bourgelat. According to Lupton, The school received immediate international recognition in the 18th century and its pedagogical model drew on the existing fields of human medicine, natural history, and comparative anatomy.

The Odiham Agricultural Society was founded in 1783 in England to promote agriculture and industry, and played an important role in the foundation of the veterinary profession in Britain. A founding member, Thomas Burgess, began to take up the cause of animal welfare and campaign for the more humane treatment of sick animals. A 1785 society meeting resolved to "promote the study of Farriery upon rational scientific principles."

Physician James Clark wrote a treatise entitled Prevention of Disease in which he argued for the professionalization of the veterinary trade, and the establishment of veterinary colleges. This was finally achieved in 1790, through the campaigning of Granville Penn, who persuaded Frenchman Benoit Vial de St. Bel to accept the professorship of the newly established veterinary college in London.

In the United States, the first schools were established in the early 19th century in Boston, New York City, and Philadelphia. In 1879, Iowa Agricultural College became the first land-grant college to establish a school of veterinary medicine.

Veterinary workers Veterinary physicians Veterinary care and management are usually led by a veterinary physician . This role is the equivalent of a physician or surgeon in human medicine, and involves postgraduate study and qualification.

In many countries, the local nomenclature for a vet is a protected term, meaning that people without the prerequisite qualifications and/or registration are not able to use the title, and in many cases, the activities that may be undertaken by a vet are restricted only to those people who are registered as vet. For instance, in the United Kingdom, as in other jurisdictions, animal treatment may be performed only by registered vets, and any persons calling themselves a vet without being registered or performing any treatment is illegal.

Most vets work in clinical settings, treating animals directly. They may be involved in a general practice, treating animals of all types; may be specialized in a specific group of animals such as companion animals, livestock, laboratory animals, zoo animals, or horses; or may specialize in a narrow medical discipline such as surgery, dermatology, laboratory animal medicine, or internal medicine.

As with healthcare professionals, vets face ethical decisions about the care of their patients. Current debates within the profession include the ethics of purely cosmetic procedures on animals, such as declawing of cats, docking of tails, cropping of ears, and debarking on dogs.

A wide range of surgeries and operations is performed on various types of animals, but not all of them are carried out by vets. In a case in Iran, for instance, an eye surgeon managed to perform a successful cataract surgery on a rooster for the first time in the world.

Paraveterinary workers Paraveterinary workers, including veterinary nurses, technicians, and assistants, either assist vets in their work, or may work within their own scope of practice, depending on skills and qualifications, including in some cases, performing minor surgery.

The role of paraveterinary workers is less homogeneous globally than that of a vet, and qualification levels, and the associated skill mix, vary widely.

Allied professions A number of professions exist within the scope of veterinary medicine, but may not necessarily be performed by vets or veterinary nurses. This includes those performing roles which are also found in human medicine, such as practitioners dealing with musculoskeletal disorders, including osteopaths, chiropractors, and physiotherapists.

Some roles are specific to animals, but which have parallels in human society, such as animal grooming and animal massage. Some roles are specific to a species or group of animals, such as farriers, who are involved in the shoeing of horses, and in many cases have a major role to play in ensuring the medical fitness of horses.

Veterinary research Veterinary research includes prevention, control, diagnosis, and treatment of diseases of animals, and basic biology, welfare, and care of animals. Veterinary research transcends species boundaries and includes the study of spontaneously occurring and experimentally induced models of both human and animal diseases and research at human-animal interfaces, such as food safety, wildlife and ecosystem health, zoonotic diseases, and public policy.

Clinical veterinary research As in medicine, randomized controlled trials also are fundamental in veterinary medicine to establish the effectiveness of a treatment. Clinical veterinary research is far behind human medical research, though, with fewer randomized controlled trials, those have a lower quality and are mostly focused on research animals. Possible improvement consists in creation of networks for inclusion of private veterinary practices in randomized controlled trials.

No studies exist on the effect of community animal health services on improving household wealth and the health status of low-income farmers.

See also Animal drug Animal science Federation of Veterinarians of Europe Lists of animal diseases National Office of Animal Health One Health Technology in veterinary medicine WikiVet By country Veterinary medicine in the United Kingdom Veterinary medicine in the United States

History of veterinary medicine in Pennsylvania History of veterinary medicine in the Philippines Veterinary Council of India Veterinary Council of Ireland References Further reading Introductory textbooks and references Monographs and other speciality texts Veterinary nursing, ophthalmology, and pharmacology.

DentistryDentistry, also known as dental medicine and oral medicine, is a branch of medicine that consists of the study, diagnosis, prevention, and treatment of diseases, disorders, and conditions of the oral cavity, commonly in the dentition but also the oral mucosa, and of adjacent and related structures and tissues, particularly in the maxillofacial area. Although primarily associated with teeth among the general public, the field of dentistry or dental medicine is not limited to teeth but includes other aspects of the craniofacial complex including the temporomandibular joint and other supporting, muscular, lymphatic, nervous, vascular, and anatomical structures.

Dentistry is often also understood to subsume the now largely defunct medical specialty of stomatology for which reason the two terms are used interchangeably in certain regions.

Dental treatments are carried out by a dental team, which often consists of a dentist and dental auxiliaries . Most dentists either work in private practices, dental hospitals or institutions .

The history of dentistry is almost as ancient as the history of humanity and civilization with the earliest evidence dating from 7000 BC to 5500 BC. Skeletal remains from Mehgarh dated to that time show evidence of teeth having been drilled with flint tools to remove decay, a method found to be "surprisingly effective". The modern movement of evidencebased dentistry calls for the use of high-quality scientific evidence to guide decision-making.

Terminology The term dentistry comes from dentist, which comes from French dentiste, which comes from the French and Latin words for tooth. The term for the associated scientific study of teeth is odontology – the study of the structure, development, and abnormalities of the teeth.

Dental treatment Dentistry usually encompasses practices related to the oral cavity. According to the World Health Organization, oral diseases are major public health problems due to their high incidence and prevalence across the globe, with the disadvantaged affected more than other socio-economic groups.

The majority of dental treatments are carried out to prevent or treat the two most common oral diseases which are dental caries and periodontal disease. Common treatments involve the restoration of teeth, extraction or surgical removal of teeth, scaling and root planing, endodontic root canal treatment and cosmetic dentistry All dentists in the United States undergo at least three years of undergraduate studies, but nearly all complete a bachelor's degree. This schooling is followed by four years of dental school to qualify as a "Doctor of Dental Surgery” or "Doctor of Dental Medicine" . Specialization in dentistry is available in the fields of Anesthesiology, Dental Public Health, Endodontics, Oral Radiology, Oral Maxillofacial Surgery, Oral Medicine, Orofacial Pain, Pathology, Orthodontics, Pediatric Dentistry, Periodontics, and Prosthodontics.

By nature of their general training they can carry out the majority of dental treatments such as restorative, prosthetic, endodontic therapy, periodontal therapy, and extraction of teeth, as well as performing examinations, radiographs, and diagnosis. Dentists can also prescribe medications such as antibiotics, sedatives, and any other drugs used in patient management. Depending on their licensing boards, general dentists may be required to complete additional training to perform sedation, dental implants, etc.

Medical lab technologistA medical laboratory scientist or clinical laboratory scientist or medical technologist performs diagnostic testing of blood and body fluids in clinical laboratories. The scope of a medical laboratory scientist's work begins with the receipt of patient or client specimens and terminates with the delivery of test results to physicians and other healthcare providers.

The utility of clinical diagnostic testing relies squarely on the validity of test methodology. To this end, much of the work done by medical laboratory scientists involves ensuring specimen quality, interpreting test results, data-logging, testing control products, performing calibration, maintenance, validation, and troubleshooting of instrumentation as well as performing statistical analyses to verify the accuracy and repeatability of testing. Medical laboratory scientists may also assist healthcare providers with test selection and specimen collection and are responsible for prompt verbal delivery of critical lab results. An estimated 70% of medical decisions are based on laboratory test results.

The most common tests performed by medical laboratory scientists are complete blood count, comprehensive metabolic panel, electrolyte panel, liver function tests, renal function tests, thyroid function test, urinalysis, coagulation profile, lipid profile, blood type, semen analysis, serological studies and routine cultures. In some facilities that have few phlebotomists or none at all, medical laboratory scientists may perform phlebotomy. Because medical laboratory scientists have many transferable technical skills, employment outside of the medical laboratory is common. Many medical laboratory scientists are employed in government positions such as the FDA, USDA, non-medical industrial laboratories, and manufacturing.

In the United Kingdom and the United States, senior laboratory scientists, who are typically post-doctoral scientists, take on significantly greater clinical responsibilities in the laboratory. In the United States these scientists may function in the role of clinical laboratory directors, while in the United Kingdom they are known as consultant clinical scientists.

Though clinical scientists have existed in the UK National Health Service for ~60 years, the introduction of formallytrained and accredited consultant-level clinical scientists is relatively new, and was introduced as part of the new Modernizing Scientific Careers framework.

Consultant clinical scientists are expected to provide expert scientific and clinical leadership alongside and, at the same level as, medical consultant colleagues. While specialists in healthcare science will follow protocols, procedures and clinical guidelines, consultant clinical scientists will help shape future guidelines and the implementation of new and emerging technologies to help advance patient care.

In the United Kingdom, healthcare scientists including clinical scientists may intervene throughout entire care pathways from diagnostic tests to therapeutic treatments and rehabilitation. Although this workforce comprises approximately 5% of the healthcare workforce in the UK, their work underpins 80% of all diagnoses and clinical decisions made.

Specialty areas Many Medical Laboratory Scientists are generalists, skilled in most areas of the clinical laboratory. However some are specialists, qualified by unique undergraduate education or additional training to perform more complex analyses than usual within a specific field. Specialties include clinical biochemistry, hematology, coagulation, microbiology, bacteriology, toxicology, virology, parasitology, mycology, immunology, immunohematology, histopathology, histocompatibility, cytopathology, genetics, cytogenetic, electron microscopy, and IVF labs. Medical Technologists specialty may use additional credentials, such as "SBB” from the American Association of Blood Banks, "SM” from the American Society for Microbiology, "SC" from the American Association for Clinical Chemistry, or "SH" from the American Society for Clinical Pathology . These additional notations may be appended to the base credential, for example, "MLSSBB". Additional information can be found in the ASCP Procedures for Examination & Certification.

Andrology Laboratory Scientist, Embryology Laboratory Scientist, and Molecular Diagnostics Technologist certifications are provided by the American Association of Bioanalysts; those with the certifications are classified as ALS, ELS, and MDxT respectively. Certified Histocompatibility Associate, Certified Histocompatibility Technologist, Certified Histocompatibility Specialist, and Diplomate of the ABHI are titles granted by the American Board of Hisocompatibility and Immunogenetics after meeting education and experience requirements and passing the required examination; those individuals would hold the credentials CHA, CHT, CHS, and D upon passing the corresponding examination.

In the United States, Medical Laboratory Scientists can be certified and employed in infection control. These professionals monitor and report infectious disease findings to help limit iatrogenic and nosocomial infections. They may also educate other healthcare workers about such problems and ways to minimize them.

In the United Kingdom the number of Clinical Scientists in a pathology discipline is typically greater, where less medically qualified pathologists train as consultants. Clinical Biochemistry, Clinical Immunology and Genomic Medicine are specialities with an abundance of UK Clinical Scientists, and where the role is well established. Infection services in the United Kingdom are generally undertaken by medically qualified Microbiologists, who may have overall responsibility for laboratory services in addition to Infection Prevention and Control responsibilities, and may be required to contribute to ward rounds and patient clinics. Therefore, the Royal College of Pathologists and Royal College of Physicians have developed Combined Infection Training, that medical trainees gain a much more patient focused experience, and undertake Physician examinations in addition to Pathology training. The end result of this is that several regional medical deaneries no longer permit Medical Doctors to train in Microbiology or Virology as single disciplines, and instead advocate dual-specialisation as Infectious Disease/Microbiology or Infectious Disease/Virology . Simultaneously the expansion of higher specialist scientist trainees in microbiology mean that many of the laboratory and scientific responsibilities of medical doctors may be taken on by Clinical Scientists, and medical doctors will instead be expected to perform a much more patient facing role. The exception in Microbiology is the sub-discipline of Virology, which is well suited to the expertise of clinical scientists due to reliance on cutting edge scientific methods, increasing use of specialised genetic technologies, and a technical understanding of virus biology, with a reduced emphasis on patient management compared with Microbiology as a whole.

It is therefore likely that many patients in UK hospitals may come into contact with Clinical Scientists working in a patient facing speciality, who may be confused with medical doctors due to the complex nature of their role.

Educational requirements Educational and licensing requirements vary by country due to differing scopes of practice and legislative differences.

Australia In Australia, medical laboratory scientists complete a four-year undergraduate degree program in medical laboratory science or Master of Medical Laboratory science . These programs should be accredited by the Australian Institute of Medical Scientists .

Canada In Canada, three-year college or technical school programs are offered that include seven semesters, two of them comprising an unpaid internship. The student graduates before taking a standard examination to be qualified as a medical laboratory technologist. Many MLTs go on to receive a Bachelor of Science degree after they are certified, but a few university programs affiliated with a college MLT program to allow students to graduate with both MLT certification and a degree such as the University of New Brunswick's Bachelor of Medical Laboratory Sciences program.

Canada is currently experiencing an increasing problem with staffing shortages in medical laboratories.

New Zealand In New Zealand, a medical laboratory scientist must complete a bachelor's degree in medical laboratory science or biological or chemical science recognized by the Medical Sciences Council of New Zealand. As part of this degree they must complete clinical placement. Once they graduate they must have worked at least six months under supervision, be registered with the Medical Sciences Counsel of New Zealand, and hold a current Annual Practicing Certificate.

Ghana In Ghana, a doctor of medical laboratory scientist is a professional with a six years professional doctorate degree in medical laboratory science, the medical laboratory scientist has four years bachelor's degree in medical laboratory science and the medical laboratory technicians has three years diploma in medical laboratory science.

The curriculum for the programme include clinical rotations, where the students get hands-on experiences in each discipline of the laboratory and performs diagnostic testing in a functioning laboratory under supervision.

Pakistan In Pakistan National Institute of Health Islamabad is the pioneer in Laboratory Sciences, College of Medical Lab Technology,, NIH, Islamabad offers 2 years F.Sc in Medical Lab Technology, Previously 2 Years B.Sc. that was discontinued and replaced by 4 years Bachelor Program in Medical Lab Sciences. University of Health Sciences, Lahore also offering 4 year Bachelor program in Medical Lab Sciences through approved colleges. University of Lahore, University of Faisalabad, University of Sargodha and Superior University Lahore offering 5-years Doctor of Medical Lab Sciences Program; Eligibility criteria for 4 years BS Medical Lab Sciences and 5 years Doctor of Medical Lab Sciences is F.Sc Pre-Medical.

United States In the United States, a medical laboratory scientist, medical technologist, or a clinical laboratory scientist typically earns a bachelor's degree in medical laboratory science, clinical laboratory science, or medical technology. Other routes include attaining a degree in biomedical science or in a life / biological science . Both routes typically requires the MLS/MT/CLS to obtain certification from a national certifying board as most laboratories exceed the federal minimum requirements established by the Clinical Laboratory Improvement Amendments .

Common comprehensive Medical laboratory scientist degree programs are set up in a few different ways.

In 3+1 programs, the student attends classroom courses for three years and complete a clinical rotation their final year of study.

In 2+2 programs, students have already completed their lower division coursework and return to complete their last two years of study in a CLS program.

In 4+1 program, students who have already completed an undergraduate program return to complete a year of medical laboratory training. The training is typically completed at a clinical site rather than a college.

The core curriculum in medical technology generally comprises 20 credits in clinical chemistry, 20 credits in hematology, and 20 credits in clinical microbiology.

During clinical rotations, the student experiences hands-on learning in each discipline of the laboratory and performs diagnostic testing in a functioning laboratory under supervision. With limited or no compensation, a student in the clinical phase of training usually works 40 hours per week for 20 to 52 weeks. Some programs in the United States have

halved the time students spend completing their clinical rotation reduced due to staffing shortages. For example, in 2015, the MLS program at the University of Minnesota reduced the clinical rotation portion of the program from 22 weeks to 12 weeks.

In the United States, a two-year academic program qualifies the graduate to work as a medical laboratory technician.

MLTs receive training more exclusively in laboratory sciences without the basic science coursework often required by MLS programs; however, there are many MLT training programs that require substantial basic didactic science course work prior to entry into a clinical practicum. Although the didactic coursework may be less for the MLT, the clinical practicum, in many cases, is similar to that of the MLS student's. This equates to MLTs who are well equipped to enter the work force with relevant and knowledge based practical application. The shorter training time may be attractive to many students, but there are disadvantages to this route. MTs, MLSs and CLSs usually earn higher salaries and have more responsibilities than MLTs. In 2018, medical laboratory technicians earned an average salary of $51,219, while medical laboratory scientists earned a salary of $67,888. An added disadvantage for MLTs is that some institutions will only employ MLSs, although that practice is starting to change due to recent efforts in cost reduction, and due to staffing shortages.

In practice, the term medical laboratory technician may apply to persons who are trained to operate equipment and perform tests, usually under the supervision of the certified medical technologist or laboratory scientist. Depending on the state where employment is granted, the job duties between MLSs and MLTs may or may not be similar. For example, in Florida, a MLT may only perform highly complex testing while under the direct supervision of a clinical laboratory technologist, a clinical laboratory supervisor, or a clinical laboratory director. This may make it impractical for a MLT to lawfully work in a Florida blood bank. California has similar restrictions on MLTs. To accommodate California's restrictions, the American Association of Bioanalysts developed a separate certification examination for California licensure. However, this exam does not include material covering the areas of immunohematology or microscopy.

Although the typical entry-level academic requirement for most MLTs is an associate degree, a 60 credit certificate program exists through military training programs; such as the U.S. Army's 68K military occupational specialty.

As in other countries, staffing shortages have become a major issue in many clinical laboratories in the United States.

Due to several factors, including boomer retirement, and inadequate recruitment and retention efforts, the medical laboratory workforce is shrinking. For the decade 2010–2020, workforce needs are expected to grow by 13%. This translates into about 11,300 positions per year that will need to be filled, with only about 5000 new graduates per year coming out of various programs. By 2025, it is estimated that the shortage of medical laboratory professionals will reach 98,700 in the U.S. United Kingdom In the United Kingdom there are two varieties of registered healthcare scientist in hospitals - Clinical Scientists and Biomedical Scientists. There is a strict and formal post graduate training programme for both careers followed by statutory registration for each with the Health & Care Professions Council UK :, for the safety and assurance of the customers - the patients. They are two similar but distinct careers with parallel but different training paths and different entry requirements.

The role of Clinical Scientists is to improve the health and well-being of patients and the public by practicing alongside doctors, nurses, and other health and social care professionals in the delivery of healthcare. Their aim is to provide expert scientific and clinical advice to clinician colleagues, to aid in the diagnosis, treatment and management of patient care.

Examples of the type of work they undertake include:

Advising, diagnosing, interpreting, and treating patients.

Advising health and social care professionals in the diagnosis and treatment of patients.

Researching the science, technology, and practise used in healthcare to innovate and improve services.

Designing, building, and operating technology for diagnosing and treating patients.

Ensuring the safety and reliability of tests and equipment used in healthcare.

Trainee Clinical Scientist posts are advertised nationally, usually between November and February on the Clinical Scientists Recruitment webpages where application forms may be obtained and electronic submission of applications can be made. These posts are for the approved Pre-registration Training Programme, designed to prepare entrants for higher professional qualifications, further clinical training and eventual Consultant responsibility.

Clinical Scientist training involves enrolment of graduates into an intensive 3-year training scheme leading to certification and eventual registration before starting the higher career structure. The basic qualification for becoming a Clinical Biochemist, Clinical Immunologist or Clinical Microbiologist is a good Honours degree in an appropriate subject: for Clinical Biochemistry, that subject might be Biochemistry or Chemistry ; for Clinical Immunology, that subject might be any life science degree with an immunology component; for Clinical Microbiology that subject might be any life science degree with a microbiology component.

Although not essential, some candidates will apply with higher degrees in an attempt to improve their chances of selection for training and several universities currently offer MSc courses in Clinical Biochemistry, Immunology and Microbiology which have been approved by the ACB or the AHCS. Full-time and 'sandwich' courses are available, and further information may be obtained from individual programmes, although the level of financial support provided varies, and should be clarified at interview. Some entrants to the profession will already have obtained a PhD, and the training and research experience that this provides is invaluable to the work of the Clinical Scientist. In larger Departments, there may be opportunities to study for a research degree after entering the profession and acquiring registration, but since this has to be fitted in with other responsibilities, it may take some years to complete. It should be clearly understood that the major role of the profession is patient care and that research, management and all the other aspects will come as side issues and not be the predominating factor in the career path. The work of Biomedical Scientists and Clinical Scientists have impact on the diagnosis and treatment of almost every patient admitted to hospitals in the United Kingdom.

The United Kingdom is facing a shortage of qualified Clinical and Biomedical Scientists. The Royal College of Pathologists and the Royal College of Physicians have pointed out the need for increased government funding for medical training programs to prevent diagnostic facilities and medical infrastructure from being overwhelmed. MSF claims that these workers have lost out financially since the decision of the then health minister Kenneth Clarke to exclude them from the pay review body in 1984.

Nigeria In Nigeria, Medical Laboratory Science is a high skilled profession charged by Act 11 of 2003 Laws of the Federation of Nigeria. The initial qualification awarded graduates of the programme, like some other medical programmes, was Associate of the Institute of Medical Laboratory Technology/Science The Medical Laboratory Science Council of Nigeria, which was established by Act. 2004 Cap 114 Laws of the Federation of Nigeria, regulates the practice of Medical Laboratory Science in Nigeria. In Nigeria, the Medical Laboratory Science programme is Bachelor of Medical Laboratory Science, regulated by National Universities Commission and by the

Medical Laboratory Science Council of Nigeria . Students at their first year are trained under the Faculty of Science in Basic Sciences and Faculty of Arts, Management and Social science in General studies and Entrepreneurship. At the 200 level, students are taught basic medical sciences and are introduced to Medical Laboratory Science. The third year of the programme marks the beginning of the professional training as students are engaged in the classroom for lectures as well as in the Hospital laboratory for the professional or practical training. At the fourth year students are taught the basics in all the special areas of Medical Laboratory Science. At the end of 400 level programme, successful students are presented for the First professional examination, to be moderated by the Medical Laboratory Science Council of Nigeria At the fifth year, students break into 4 core or specialized areas of Medical Laboratory Science, namely: medical microbiology/parasitology, chemical pathology/immunology, haematology/blood transfusion science and histopathology/cytopathology. At the end of the fifth year, suitable students are presented for final professional examination by the Medical Laboratory Science Council of Nigeria.

Certification and licensing United States There are currently three major certification agencies in the United States of America for clinical laboratory scientists.

They are the American Association of Bioanalysts, the American Medical Technologists, and the American Society for Clinical Pathology . All three national accrediting agencies will certify scientists in the clinical laboratory as generalist .

The American Association of Bioanalysts and the American Medical Technologists certifications continue to use the traditional designation Medical Technologist, while the American Society for Clinical Pathology has adopted the designation of Medical Laboratory Scientist . Regardless of terminology, these highly qualified individuals serve as scientists in the clinical laboratory.

There are two other organizations that have previously provided proficiency examinations to clinical laboratory scientist.

The first, is the US Department of Health and Human Services. The second, is the National Credentialing Agency for Laboratory Personnel . The NCA was absorbed by the American Society for Clinical Pathology in 2009 and promptly dissolved.

In the United States, the Clinical Laboratory Improvement Amendments define the level of qualification required to perform tests of various complexity. Clinical Laboratory Scientists, Medical Technologists and Medical Laboratory Scientists are near the highest level of qualification among general testing personnel and are usually qualified to perform the most complex clinical testing including HLA testing and blood type reference testing. Provider Performed Microscopy, or PPM and Cytology have additional requirements.

In addition to the national certification, 12 states and Puerto Rico also require a state license. Puerto Rico, in order to provide the state license, requires either a local board certification with a state examination, or any of both the ASCP and the NCA. Minnesota, Texas, Illinois, Massachusetts, Michigan, Vermont, Washington, New Jersey, Iowa, Utah, Ohio, South Carolina, Wyoming, Pennsylvania, Virginia, South Dakota, Delaware, Missouri, and Alaska are currently attempting to obtain licensure. All states require documentation from a professional certification agency before issuing a state certification. A person applying for state certification may also be expected to submit fingerprints, education and training records, and competency certification. Some states also require completion of a specified number of continuing education contact hours prior to issuing or renewing a license. Licensing is somewhat controversial as it adds a bureaucratic layer in a field that is severely understaffed. Simply requiring testing personnel to obtain and maintain their national certification would help ensure competent testing personnel without increasing costs to testing personnel.

Some states recognize another state's license if it is equal or more stringent, but currently California does not recognize any other state license.

United Kingdom In the United Kingdom all clinical scientists and biomedical scientists have had to be registered with the Health & Care Professions Council in order to work unsupervised, to develop through the careers grades of their profession and to use the protected titles of "Clinical Scientist" or "Biomedical Scientist". The HCPC registers nearly 200,000 healthcare professionals and while success in an approved degree course from an accredited University is sufficient for all other professions, both clinical scientists and biomedical scientists have post graduate training and no approved degree courses. Autonomous assessment of applicants in these two professions with subsequent certification for successful ones, is the only approved UK route to registration for them.

"Clinical Scientist", just as "Biomedical Scientist", is a protected title under the law. The HCPC can strike people off the register for malpractice in just the same way as for doctors with the General Medical Council.

Those who are working in "Trainee" positions in the profession are permitted to use the title with an appropriate caveat, for example – "Pre-registration Clinical Scientist", Trainee Clinical Scientist, etc. Alternatively some may use titles specific to the discipline they train in, such as Trainee Clinical Biochemist", "Clinical Immunologist in Training" or “ Pre-Registrant Clinical Microbiologist” which is also perfectly acceptable since it is not implying the protected "Clinical Scientist" title of fully qualified and registered practitioners. It is against the law to formally work with the title of “Clinical Scientist” without professional registration.

Nigeria In Nigeria successful student at the end of the training in both academic and professional assessments with respect to the graduation requirements is certified by the respective University, inducted and licensed by the Medical Laboratory Science Council of Nigeria after successful internship training. http://mlscn.gov.ng Further education As in many healthcare professions, a Medical Laboratory Scientist may pursue higher education to advance or further specialize in their career.

Master of Science, Master of Business Administration, Master of Health Administration, Doctor of medical laboratory science for specialization, education and management roles.

Doctor of Philosophy for management and directorship roles in the clinical laboratory as well as for academic research and professorship. Doctors of Philosophy holding a degree in a biological science, and who are board certified by a CLIAapproved entity, are qualified as a medical laboratory director.

Doctor of Medicine or Doctor of clinical laboratory Science - this is the position that qualifies an individual to oversee or direct almost all types of clinical laboratories. Under U.S. CLIA laws, a requirement of at least year of clinical laboratory experience or pathology residency must be met.

In the United Kingdom The Modernising Scientific Careers programme sets out for the first time a comprehensive training and career framework for the whole healthcare science workforce inclusive of the more than 50 different scientific professional specialisms. In its conception it aimed to provide a coherent framework that was accessible, affordable and designed specifically to both capture scientific and technological advances and to provide improved outcomes for patients, the service and professionals. A key aspect of the framework from the start was the formalisation of training to develop talented clinical scientists to undertake quality assured Higher Specialist Scientist Training programmes to prepare them for roles as Consultant Clinical Scientists. It is envisaged that Consultant Clinical Scientists will work synergistically and in partnership with their medical colleagues and within multiprofessional clinical teams to

support clinical scientific practice aimed at quality improvement, innovation and world-class outcomes for patients. This scientific expertise and leadership will provide important benefits and added value to patients and to the service as it moves forward through the 21st century. This will bring to fruition the vision of science and realise the potential of scientific and technological advances for both translational and personalised medicine.

Training through the Higher Specialist Scientist Training pathway is discipline specific. For life science disciplines the training curriculum and formal examinations are administered by the Royal College of Pathologists. The life science training pathway for Clinical Scientists follows a similar pathway to that undertaken by medically qualified specialist registrars in pathology. Clinical Scientists are therefore the only discipline of non-medical healthcare professionals examined by a Medical Royal College. Clinical Scientists who attain both part 1 examination certification and part 2 certification are awarded Fellowship of the Royal College of Pathologists and are deemed to have the knowledge and expertise expected of a consultant level scientist. Consultant Clinical Scientist posts generally require candidates to have completed FRCPath qualification to be eligible.

All Clinical Scientists regardless of seniority or specialisation may have other responsibilities including academic appointments, responsibilities as clinical lead for a pathology service, or may have wider hospital responsibilities such as Directorship of Infection Prevention and Control, or responsibility for the hospital's Research and Development strategy.

Junior clinical scientists may become involved in academic research, working towards award of a Ph.D. or DClinSci Job title The informal abbreviations of job titles may be a source of confusion. In the United States Medical Laboratory Scientist and Medical Technologists or are often called "med techs", but this shorthand term is shared by other healthcare employees, including pharmacy techs, radiographers, and respiratory therapists.

In the United States there is a formal distinction between an MLT and a MT/MLS. Often, MT/MLS have at least a bachelor's degree, while MLT have an associate degree. However, due to grandfathering rules and certification requirements between the boards of registry, some MT/MLS may only have an associate degree. Scientists and technologists generally earn a higher income than technicians, have more responsibilities, and have more opportunities for advancement.

In the United Kingdom, there are defined training pathways leading to professional registration as either a Clinical Scientist, or as a Biomedical Scientist. The role descriptions for these healthcare scientists are very different, where clinical scientists generally undertake non-routine research and development, as well as improving and providing clinical service using scientific expertise. Biomedical Scientists in the United Kingdom are similar to the role of MLT and MT/CLS described above, and have similar regulatory requirements for professional regulation. Clinical Scientists in the United Kingdom may struggle with a lack of professional recognition. This is in part due to the myriad job titles used to describe them including Clinical Physiologists, Medical Physicists, and Clinical Biochemists, which generally mean the public and other healthcare workers assume Clinical Scientists to be medically qualified doctors, due to the sometimes complex nature of the role.

See also Laboratory centrifuge Laboratory information system Medical technology Medical laboratory

Phlebotomist Reference ranges for common blood tests Urine test Allied health professions Automated analyser Blood bank Blood test Biomedical Scientist similar career outside of the US Body fluids Clinical pathology ISO 15189.

NursingBut there is evidence of international shortages of qualified nurses. Many nurses provide care within the ordering scope of physicians, and this traditional role has shaped the public image of nurses as care providers. Nurse practitioners are however permitted by most jurisdictions to practice independently in a variety of settings. Since the postwar period, nurse education has undergone a process of diversification towards advanced and specialized credentials, and many of the traditional regulations and provider roles are changing.

Nurses develop a plan of care, working collaboratively with physicians, therapists, the patient, the patient's family, and other team members that focus on treating illness to improve quality of life. In the United Kingdom and the United States, advanced practice nurses, such as clinical nurse specialists and nurse practitioners, diagnose health problems and prescribe medications and other therapies, depending on individual state regulations. Nurses may help coordinate the patient care performed by other members of a multidisciplinary health care team such as therapists, medical practitioners, and dietitians. Nurses provide care both interdependently, for example, with physicians, and independently as nursing professionals.

History Traditional Nursing historians face the challenge of determining whether care provided to the sick or injured in antiquity was nursing care. In the fifth century BC, for example, the Hippocratic Collection in places describes skilled care and observation of patients by male "attendants," who may have been early nurses. Around 600 BC in India, it is recorded in Sushruta Samhita, Book 3, and Chapter V about the role of the nurse as "the different parts or members of the body as mentioned before including the skin, cannot be correctly described by one who is not well versed in anatomy. Hence, any one desirous of acquiring a thorough knowledge of anatomy should prepare a dead body and carefully, observe, by dissecting it, and examine its different parts."

Before the foundation of modern nursing, members of religious orders such as nuns and monks often provided nursinglike care. Examples exist in Christian, Islamic and Buddhist traditions amongst others. Phoebe, mentioned in Romans 16 has been described in many sources as "the first visiting nurse". These traditions were influential in the development of the ethos of modern nursing. The religious roots of modern nursing remain in evidence today in many countries. One example in the United Kingdom is the use of the historical title "sister" to refer to a senior nurse in the past.

During the Reformation of the 16th century, Protestant reformers shut down the monasteries and convents, allowing a few hundred municipal hospices to remain in operation in northern Europe. Those nuns who had been serving as nurses were given pensions or told to get married and stay home. Nursing care went to the inexperienced as traditional caretakers, rooted in the Roman Catholic Church, were removed from their positions. The nursing profession suffered a major setback for approximately 200 years.

19th century During the Crimean War the Grand Duchess Elena Pavlovna issued the call for women to join the Order of Exaltation of the Cross for the year of service in the military hospitals. The first section of twenty-eight "sisters", headed by Aleksandra Petrovna Stakhovich, the Directress of the Order, went off to the Crimea early in November 1854.

Florence Nightingale laid the foundations of professional nursing after the Crimean War. Her Notes on Nursing became popular. The Nightingale model of professional education, having set up the first school of nursing that is connected to a

continuously operating hospital and medical school, spread widely in Europe and North America after 1870. Nightingale was also a pioneer of the graphical presentation of statistical data.

Nightingale's recommendations built upon the successes of Jamaican "doctresses" such as Mary Seacole, who like Nightingale, served in the Crimean War. Seacole practised hygiene and the use of herbs in healing wounded soldiers and those suffering from diseases in the 19th century in the Crimea, Central America, and Jamaica. Her predecessors had great success as healers in the Colony of Jamaica in the 18th century, and they included Seacole's mother, Mrs. Grant, Sarah Adams, Cubah Cornwallis, and Grace Donne, the mistress and doctress to Jamaica's wealthiest planter, Simon Taylor.

Other important nurses in the development of the profession include: Agnes Hunt from Shropshire was the first orthopedic nurse and was pivotal in the emergence of the orthopedic hospital The Robert Jones & Agnes Hunt Hospital in Oswestry, Shropshire.

Agnes Jones, who established a nurse training regime at the Brownlow Hill infirmary, Liverpool, in 1865.

Linda Richards, who established quality nursing schools in the United States and Japan, and was officially the first professionally trained nurse in the US, graduating in 1873 from the New England Hospital for Women and Children in Boston.

Clarissa Harlowe "Clara" Barton, a pioneer American teacher, patent clerk, nurse, and humanitarian, and the founder of the American Red Cross.

Saint Marianne Cope, a Sister of St. Francis who opened and operated some of the first general hospitals in the United States, instituting cleanliness standards which influenced the development of America's modern hospital system.

Catholic orders such as Little Sisters of the Poor, Sisters of Mercy, Sisters of St. Mary, St. Francis Health Services, Inc. and Sisters of Charity built hospitals and provided nursing services during this period. In turn, the modern deaconess movement began in Germany in 1836. Within a half century, there were over 5,000 deaconesses in Europe.

Formal use of nurses in the modern military began in the latter half of the nineteenth century. Nurses saw active duty in the First Boer War, the Egyptian Campaign, and the Sudan Campaign .

20th century Hospital-based training came to the fore in the early 1900s, with an emphasis on practical experience. The Nightingalestyle school began to disappear. Hospitals and physicians saw women in nursing as a source of free or inexpensive labor.

Exploitation of nurses was not uncommon by employers, physicians, and educational providers.

Many nurses saw active duty in World War I, but the profession was transformed during the Second World War. British nurses of the Army Nursing Service were part of every overseas campaign. More nurses volunteered for service in the US Army and Navy than any other occupation. The Nazis had their own Brown Nurses, 40,000 strong. Two dozen German Red Cross nurses were awarded the Iron Cross for heroism under fire.

The modern era saw the development of undergraduate and post-graduate nursing degrees. Advancement of nursing research and a desire for association and organization led to the formation of a wide variety of professional organizations and academic journals. Growing recognition of nursing as a distinct academic discipline was accompanied by an awareness of the need to define the theoretical basis for practice.

In the 19th and early 20th century, nursing was considered a women's profession, just as doctoring was a men's profession. With increasing expectations of workplace equality during the late 20th century, nursing became an officially gender-neutral profession, though in practice the percentage of male nurses remains well below that of female physicians in the early 21st century.

Definition Although nursing practice varies both through its various specialties and countries, these nursing organizations offer the following definitions: As a profession The authority for the practice of nursing is based upon a social contract that delineates professional rights and responsibilities as well as mechanisms for public accountability. In almost all countries, nursing practice is defined and governed by law, and entrance to the profession is regulated at the national or state level.

The aim of the nursing community worldwide is for its professionals to ensure quality care for all, while maintaining their credentials, code of ethics, standards, and competencies, and continuing their education. There are a number of educational paths to becoming a professional nurse, which vary greatly worldwide; all involve extensive study of nursing theory and practice as well as training in clinical skills.

Nurses care for individuals of all ages and cultural backgrounds who are healthy and ill in a holistic manner based on the individual's physical, emotional, psychological, intellectual, social, and spiritual needs. The profession combines physical science, social science, nursing theory, and technology in caring for those individuals.

To work in the nursing profession, all nurses hold one or more credentials depending on their scope of practice and education. In the United States, a Licensed Practical Nurse works independently or with a Registered Nurse . The most significant difference between an LPN and RN is found in the requirements for entry to practice, which determines entitlement for their scope of practice. RNs provide scientific, psychological, and technological knowledge in the care of patients and families in many health care settings. RNs may earn additional credentials or degrees.

In the United States, multiple educational paths will qualify a candidate to sit for the licensure examination as an RN. The Associate Degree in Nursing is awarded to the nurse who has completed a two-year undergraduate academic degree awarded by community colleges, junior colleges, technical colleges, and bachelor's degree-granting colleges and universities upon completion of a course of study usually lasting two years. It is also referred to as Associate in Nursing, Associate of Applied Science in Nursing, or Associate of Science in Nursing. The Bachelor of Science in Nursing is awarded to the nurse who has earned an American four-year academic degree in the science and principles of nursing, granted by a tertiary education university or similarly accredited school. After completing either the LPN or either RN education programs in the United States, graduates are eligible to sit for a licensing examination to become a nurse, the passing of which is required for the nursing license. The National Licensure Examination test is a standardized exam that nurses take to become licensed. It costs two-hundred dollars to take the NCLEX. It examines a nurse’s ability to properly care for a client. Study books and practice tests are available for purchase.

Some nurses follow the traditional role of working in a hospital setting. Other options include: pediatrics, neonatal, maternity, OBGYN, geriatrics, ambulatory, and nurse anesthetists and informatics. There are many other options nurses can explore depending on the type of degree and education acquired. RNs may also pursue different roles as advanced practice nurses.

Nurses are not doctors' assistants. This is possible in certain situations, but nurses more often are independently caring for their patients or assisting other nurses. RNs treat patients, record their medical history, provide emotional support,

and provide follow-up care. Nurses also help doctors perform diagnostic tests. Nurses are almost always working on their own or with other nurses. Nurses will assist doctors in the emergency room or in trauma care when help is needed.

Gender issues Despite equal opportunity legislation, nursing has continued to be a female-dominated profession in many countries; according to the WHO's 2020 State of the World's Nursing, approximately 90% of the nursing workforce is female. For instance, the male-to-female ratio of nurses is approximately 1:19 in Canada and the United States. This ratio is represented around the world. Notable exceptions include Francophone Africa, which includes the countries of Benin, Burkina Faso, Cameroon, Chad, Congo, Côte d'Ivoire, the Democratic Republic of Congo, Djibouti, Guinea, Gabon, Mali, Mauritania, Niger, Rwanda, Senegal, and Togo, which all have more male than female nurses. In Europe, in countries such as Spain, Portugal, Czech Republic and Italy, over 20% of nurses are male. The number of male nurses in the United States doubled between 1980 and 2000. However female nurses are still more common, but male nurses receive more pay on average.

Theory and process Nursing practice is the actual provision of nursing care. In providing care, nurses implement the nursing care plan using the nursing process. This is based around a specific nursing theory which is selected in consideration with the care setting and the population served. In providing nursing care, the nurse uses both nursing theory and best practice derived from nursing research.

In general terms, the nursing process is the method used to assess and diagnose needs, plan outcomes and interventions, implement interventions, and evaluate the outcomes of the care provided. Like other disciplines, the profession has developed different theories derived from sometimes diverse philosophical beliefs and paradigms or worldviews to help nurses direct their activities to accomplish specific goals.

Scope of activities Activities of daily living assistance Assisting in activities of daily living are skills required in nursing as well as other professions such as nursing assistants.

This includes assisting in patient mobility, such as moving an activity intolerant patient within bed. For hygiene, this often involves bed baths and assisting with urinary and bowel elimination.

Medication Medication management and administration are part of most hospital nursing roles, however, prescribing authority varies between jurisdictions. In many areas, registered nurses administer and manage medications prescribed by a professional with full prescribing authority such as a nurse practitioner or physician. As nurses are responsible for evaluating patients throughout their care - including before and after medication administration - adjustments to medications are often made through a collaborative effort between the prescriber and the nurse. Regardless of the prescriber, nurses are legally responsible for the drugs they administer. There may be legal implications when there is an error in a prescription, and the nurse could be expected to have noted and reported the error. In the United States, nurses have the right to refuse any medication administration that they deem to be potentially harmful to the patient.

In the United Kingdom there are some nurses who have taken additional specialist training that allows them to prescribe any medications from their scope of practice.

Patient education

The patient's family is often involved in the education. Effective patient education leads to fewer complications and hospital visits.

Specialties and practice settings Nursing is the most diverse of all health care professions. Nurses practice in a wide range of settings but generally nursing is divided depending on the needs of the person being nursed.

The major populations are: Communities/public Family/individual across the lifespan Adult-gerontology Pediatrics Neonatal Women’s health/gender-related Mental health Informatics Acute care hospitals Ambulatory settings School/college infirmaries There are also specialist areas such as cardiac nursing, orthopedic nursing, palliative care, perioperative nursing, obstetrical nursing, oncology nursing, nursing informatics, telemarking, radiology, and emergency nursing.

Nurses practice in a wide range of settings, including hospitals, private homes, schools, and pharmaceutical companies.

Nurses work in occupational health settings, free-standing clinics and physician offices, nurse-led clinics, long-term care facilities and camps. They also work on cruise ships and in military service. Nurses act as advisers and consultants to the health care and insurance industries. Many nurses also work in the health advocacy and patient advocacy fields at companies such as Health Advocate, Inc. helping in a variety of clinical and administrative issues. Some are attorneys and others work with attorneys as legal nurse consultants, reviewing patient records to assure that adequate care was provided and testifying in court. Nurses can work on a temporary basis, which involves doing shifts without a contract in a variety of settings, sometimes known as per diem nursing, agency nursing or travel nursing. Nurses work as researchers in laboratories, universities, and research institutions. Nurses have also been delving into the world of informatics, acting as consultants to the creation of computerized charting programs and other software. Nurse authors publish articles and books to provide essential reference materials.

Occupational hazards Internationally, there is a serious shortage of nurses. One reason for this shortage is due to the work environment in which nurses practice. In a recent review of the empirical human factors and ergonomic literature specific to nursing performance, nurses were found to work in generally poor environmental conditions. Some countries and states have passed legislation regarding acceptable nurse-to-patient ratios.

The fast-paced and unpredictable nature of health care places nurses at risk for injuries and illnesses, including high occupational stress. Nursing is a particularly stressful profession, and nurses consistently identify stress as a major workrelated concern and have among the highest levels of occupational stress when compared to other professions. This stress is caused by the environment, psychosocial stressors, and the demands of nursing, including new technology that must be mastered, the emotional labor involved in nursing, physical labor, shift work, and high workload. This stress puts nurses at risk for short-term and long-term health problems, including sleep disorders, depression, mortality, psychiatric disorders, stress-related illnesses, and illness in general. Nurses are at risk of developing compassion fatigue and moral distress, which can worsen mental health. They also have very high rates of occupational burnout and emotional exhaustion. Burnout and exhaustion increase the risk for illness, medical error, and suboptimal care provision.

Nurses are also at risk for violence and abuse in the workplace. Violence is typically perpetrated by non-staff, whereas abuse is typically perpetrated by other hospital personnel. Of American nurses, 57% reported in 2011 that they had been threatened at work; 17% were physically assaulted. Lumbar supports have also been trialed.

Worldwide America United States In the US, scope of practice is determined by the state or territory in which a nurse is licensed. Each state has its own laws, rules, and regulations governing nursing care. Usually the making of such rules and regulations is delegated to a state board of nursing, which performs day-to-day administration of these rules, licenses for nurses and nursing assistants, and makes decisions on nursing issues. In some states, the terms "nurse" or "nursing" may only be used in conjunction with the practice of a registered nurse or licensed practical or vocational nurse .

In the hospital setting, registered nurses often delegate tasks to LPNs and unlicensed assistive personnel.

RNs are not limited to employment as bedside nurses. They are employed by physicians, attorneys, insurance companies, governmental agencies, community/public health agencies, private industry, school districts, ambulatory surgery centers, among others. Some registered nurses are independent consultants who work for themselves, while others work for large manufacturers or chemical companies. Research nurses conduct or assist in the conduct of research or evaluation in many areas such as biology, psychology, human development, and health care systems.

Many employers offer flexible work schedules, child care, educational benefits, and bonuses. About 21 percent of registered nurses are union members or covered by union contract.

Nursing is the nation's largest health care profession. In 2017, there were more than 4,015,250 registered nurses and 922,196 licensed practical nurses nationwide. Of all licensed RNs, 2.6 million or 84.8% are employed in nursing. Nurses comprise the largest single component of hospital staff, are the primary providers of hospital patient care, and deliver most of the nation's long-term care. The primary pathway to professional nursing, as compared to technical-level practice, is the four-year Bachelor of Science in Nursing degree. Registered nurses are prepared either through a BSN program; a three-year associate degree in nursing; or a three-year hospital training program, receiving a hospital diploma. All take the same state licensing exam.

Educational and licensure requirements Diploma in Nursing

The oldest method of nursing education is the hospital-based diploma program, which lasts approximately three years.

Students take between 30 and 60 credit hours in anatomy, physiology, microbiology, nutrition, chemistry, and other subjects at a college or university, then move on to intensive nursing classes. Until 1996, most RNs in the US were initially educated in nursing by diploma programs. According to the Health Services Resources Administration's 2000 Survey of Nurses only six percent of nurses who graduated from nursing programs in the United States received their education at a Diploma School of Nursing.

Associate Degree in Nursing The most common initial nursing education is a two-year Associate Degree in Nursing, a two-year college degree referred to as an ADN. Some four-year colleges and universities also offer the ADN. Associate degree nursing programs have prerequisite and corequisite courses and ultimately stretch out the degree-acquiring process to about three years or greater.

Bachelor of Science in Nursing The third method is to obtain a Bachelor of Science in Nursing, a four-year degree that also prepares nurses for graduate-level education. For the first two years in a BSN program, students usually obtain general education requirements and spend the remaining time in nursing courses. In some new programs the first two years can be substituted for an active LPN license along with the required general studies. Advocates for the ADN and diploma programs state that such programs have an on the job training approach to educating students, while the BSN is an academic degree that emphasizes research and nursing theory. Some states require a specific amount of clinical experience that is the same for both BSN and ADN students. A BSN degree qualifies its holder for administrative, research, consulting and teaching positions that would not usually be available to those with an ADN, but is not necessary for most patient care functions. Nursing schools may be accredited by either the Accreditation Commission for Education in Nursing or the Commission on Collegiate Nursing Education.

Graduate education Advanced education in nursing is done at the master's and doctoral levels. It prepares the graduate for specialization as an advanced practice registered nurse or for advanced roles in leadership, management, or education. The clinical nurse leader is an advanced generalist who focuses on the improvement of quality and safety outcomes for patients or patient populations from an administrative and staff management focus. Doctoral programs in nursing prepare the student for work in nursing education, health care administration, clinical research, public policy, or advanced clinical practice. Most programs confer the PhD in nursing or Doctor of Nursing Practice.

Advanced practice registered nurse Areas of advanced nursing practice include that of a nurse practitioner, a certified nurse midwife, a certified registered nurse anesthetist, or a clinical nurse specialist . Nurse practitioners and CNSs work assessing, diagnosing and treating patients in fields as diverse as family practice, women's health care, emergency nursing, acute/critical care, psychiatry, geriatrics, or pediatrics, additionally, a CNS usually works for a facility to improve patient care, do research, or as a staff educator.

Licensure examination Completion of any one of these three educational routes allows a graduate nurse to take the NCLEX-RN, the test for licensure as a registered nurse, and is accepted by every state as an adequate indicator of minimum competency for a new graduate. However, controversy exists over the appropriate entry-level preparation of RNs. Some professional organizations believe the BSN should be the sole method of RN preparation and ADN graduates should be licensed as

"technical nurses" to work under the supervision of BSN graduates. Others feel the on-the-job experiences of diploma and ADN graduates makes up for any deficiency in theoretical preparation.

Shortage in the United States RNs are the largest group of health care workers in the United States, with about 2.7 million employed in 2011. It has been reported that the number of new graduates and foreign-trained nurses is insufficient to meet the demand for registered nurses; this is often referred to as the nursing shortage and is expected to increase for the foreseeable future.

There are data to support the idea that the nursing shortage is a voluntary shortage. In other words, nurses are leaving nursing of their own volition. In 2006 it was estimated that approximately 1.8 million nurses chose not to work as a nurse. The Bureau of Labor Statistics reported that 296,900 healthcare jobs were created in 2011. RNs make up the majority of the healthcare work force, therefore these positions will be filled primarily by nurses. The BLS also states that by 2020, there will be 1.2 million nursing job openings due to an increase in the workforce, and replacements.

Causes The International Council of Nursing, the largest international health professional organization in the world, recognizes the shortage of nurses as a growing crisis in the world. This shortage impacts the healthcare of everyone worldwide. One of the many reasons is that nurses who pursue to become nurses do so very late in their lives. This leads to a nonlengthy employment time. A national survey prepared by the Federation of Nurses and Health Professionals in 2001 found that one in five nurses plans to leave the profession within five years because of unsatisfactory working conditions, including low pay, severe under staffing, high stress, physical demands, mandatory overtime, and irregular hours. Approximately 29.8 percent of all nursing jobs are found in hospitals.

Lovey, Campbell, and Green voiced their concern about the shortage of nurses, citing Fang, Wilsey-Wisniewski, & Bed Nash, 2006, who state that over 40,000 qualified nursing applicants were turned away in the 2005–2006 academic year from baccalaureate nursing programs due to a lack of masters and doctoral qualified faculty, and that this number was increased over 9,000 from 32,000 qualified but rejected students from just two years earlier. Several strategies have been offered to mitigate this shortage including; Federal and private support for experienced nurses to enhance their education, incorporating more hybrid/blended nursing courses, and using simulation in lieu of clinical training experiences.

Furthermore, there is a shortage of academically qualified instructors to teach at schools of nursing worldwide. The serious need for educational capacity is not being met, which is the underlying most important preparation resource for the nurses of tomorrow. The decrease in faculty everywhere is due to many factors including decrease in satisfaction with the workforce, poor salaries, and reduction in full-time equivalent. Throughout the span of 6 years the nursing faculty shortage has been written about an increasing amount. There is no clear consensus or an organized plan on how to fix the ongoing issue.

Continuing education With health care knowledge growing steadily, nurses can stay ahead of the curve through continuing education.

Continuing education classes and programs enable nurses to provide the best possible care to patients, advance nursing careers, and keep up with Board of Nursing requirements. The American Nurses Association and the American Nursing Credentialing Center are devoted to ensuring nurses have access to quality continuing education offerings. Continuing education classes are calibrated to provide enhanced learning for all levels of nurses. Many States also regulate Continuing Nursing Education. Nursing licensing boards requiring Continuing Nursing Education as a condition for licensure, either initial or renewal, accept courses provided by organizations that are accredited by other state licensing boards, by the American Nursing Credentialing Center, or by organizations that have been designated as an approver of

continuing nursing education by ANCC. There are some exceptions to this rule including the state of California, Florida and Kentucky. National Healthcare Institute has created a list to assist nurses in determining their CNE credit hours requirements. While this list is not all inclusive, it offers details on how to contact nursing licensing boards directly.

Board certification Professional nursing organizations, through their certification boards, have voluntary certification exams to demonstrate clinical competency in their particular specialty. Completion of the prerequisite work experience allows an RN to register for an examination, and passage gives an RN permission to use a professional designation after their name. For example, passage of the American Association of Critical-care Nurses specialty exam allows a nurse to use the initials 'CCRN' after his or her name. Other organizations and societies have similar procedures.

The American Nurses Credentialing Center, the credentialing arm of the American Nurses Association, is the largest nursing credentialing organization and administers more than 30 specialty examinations.

Correctional nursing Due to its large prison population, the United States needs many correctional nurses to help inmates receive proper health-care, including mental health treatments for prisoners with psychological issues.

Canada History Canadian nursing dates back to 1639 in Quebec with the Augustine nuns. These nuns were trying to open a mission that cared for the spiritual and physical needs of patients. The establishment of this mission created the first nursing apprenticeship training in North America. The nursing education in Latin America and the Caribbean includes the principles and values of the Universal Health and primary health care. These principles underpin transformative education modalities such as critical and complex thinking development, problem-solving, evidence-based clinical decision-making, and lifelong learning. The Pan American Health Organization/World Health Organization proposes the Strategy for Universal Access to Health and Universal Health Coverage to improve health outcomes and other basic objectives of health systems based on the right of each person to receive the best standard of health, without exposing people to financial difficulties through nursing intervention.

Europe Spain See Nursing in Spain United Kingdom To practice lawfully as a registered nurse in the United Kingdom, the practitioner must hold a current and valid registration with the Nursing and Midwifery Council. The title "Registered Nurse" can only be granted to those holding such registration. This protected title is laid down in the Nurses, Midwives and Health Visitors Act, 1997. From April 2016, nurses in the United Kingdom are expected to revalidate every three years which involves providing evidence of further development and active practice.

First and second level First-level nurses make up the bulk of the registered nurses in the UK. They were previously known by titles such as Registered General Nurse, Registered Sick Children's Nurse, Registered Mental Nurse, and Registered Nurse Mentally

Handicapped . The titles used now are similar, including Registered Nurse Adult, Registered Nurse Child, Registered Nurse Mental Health, and Registered Nurse Learning Disabilities . Second-level nurse training is no longer provided; however, they are still legally able to practice in the United Kingdom as a registered nurse. Many have now either retired or undertaken conversion courses to become first-level nurses. They are entitled to refer to themselves as registered nurses as their registration is on the Nursing & Midwifery Council register of nurses, although most refer to themselves as Enrolled Nurses or State Enrolled Nurses.

Advanced practice Nurse practitioners – Most of these nurses obtain a minimum of a master's degree and a desired post grad certificate.

They often perform roles similar to those of physicians and physician assistants. They can prescribe medications as independent or supplementary prescribers, although they are still legally regulated, unlike physician's assistants. Most Nurse Practitioners have referral and admission rights to hospital specialties. They commonly work in primary care surgeries), Accident and Emergency departments, or pediatrics although they are increasingly being seen in other areas of practice. In the UK, the title "nurse practitioner" is legally protected.

Specialist community public health nurses – traditionally district nurses and health visitors, this group oversees research and publication activities.

Lecturer-practitioners – these nurses work both in the National Health Service, and in universities. They typically work 2– 3 days per week in each setting. In university, they train pre-registration student nurses, and often teach on specialist courses post-registration nurses.

Lecturers – these nurses are not employed by the NHS. Instead they work full-time in universities, both teaching and performing research.

Managers Many nurses who have worked in clinical settings for a long time choose to leave clinical nursing and join the ranks of the NHS management. This used to be seen as a natural career progression for those who had reached ward management positions, however with the advent of specialist nursing roles, this has become a less attractive option.

Nonetheless, many nurses fill positions in the senior management structure of NHS organizations, some even as board members. Others choose to stay a little closer to their clinical roots by becoming clinical nurse managers or modern matrons.

Nurse education Pre-registration To become a registered nurse, one must complete a program recognized by the Nursing and Midwifery Council.

Currently, this involves completing a degree, available from a range of universities offering these courses, in the chosen branch specialty, leading to both an academic award and professional registration as a 1st level registered nurse. Such a course is a 50/50 split of learning in university and in practice.

These courses are three years’ long. The first year is known as the common foundation program, and teaches the basic knowledge and skills required of all nurses. Skills included in the CFP may include communication, taking observations, administering medication and providing personal care to patients. The remainder of the program consists of training specific to the student's chosen branch of nursing. These are: Child nursing.

Mental health nursing.

Learning disabilities nursing.

As of 2013, the Nursing and Midwifery Council will require all new nurses qualifying in the UK to hold a degree qualification. However, those nurses who hold a diploma, or even a certificate in nursing are still able to legally practice in the UK, although they are able to undertake university modules to obtain enough credits to top up to a degree.

Midwifery training is similar in length and structure, but is sufficiently different that it is not considered a branch of nursing. There are shortened programs to allow nurses already qualified in the adult branch to hold dual registration as a nurse and a midwife. Shortened courses lasting 2 years also exist for graduates of other disciplines to train as nurses.

This is achieved by more intense study and a shortening of the common foundation program. student nurses in England and Wales can apply for a bursary from the government to support them during their nurse training, and may also be eligible for a student loan, although there has been speculation that this will not be available in the future. Student nurses in Scotland still receive a standard bursary which is not means tested, and their tuition fees continue to be paid – however, they are not eligible for student loans.

Before Project 2000, nurse education was the responsibility of hospitals and was not based in universities; hence many nurses who qualified prior to these reforms do not hold an academic award.

Post-registration After the point of initial registration, there is an expectation that all qualified nurses will continue to update their skills and knowledge. The Nursing and Midwifery Council insists on a minimum of 35 hours of education every three years, as part of its post registration education and practice requirements.

There are also opportunities for many nurses to gain additional clinical skills after qualification. Annulation, venipuncture, intravenous drug therapy and male catheterization are the most common, although there are many others, which some nurses undertake.

Many nurses who qualified with a diploma choose to upgrade their qualification to a degree by studying part-time.

Many nurses prefer this option to gaining a degree initially, as there is often an opportunity to study in a specialist field as a part of this upgrading. Financially, in England, it was also much more lucrative, as diploma students get the full bursary during their initial training, and employers often pay for the degree course as well as the nurse's salary.

To become specialist nurses or nurse educators, some nurses undertake further training above bachelor's degree level.

Master's degrees exist in various healthcare related topics, and some nurses choose to study for PhDs or other higher academic awards. District nurses and health visitors are also considered specialist nurses, and to become such they must undertake specialist training. This is a one-year full-time degree.

All newly qualifying district nurses and health visitors are trained to prescribe from the Nurse Prescribers' Formulary, a list of medications and dressings typically useful to those carrying out these roles. Many of these nurses will also undertake training in independent and supplementary prescribing, which allows them to prescribe almost any drug in the British National Formulary. This has been the cause of a great deal of debate in both medical and nursing circles.

European Union In the European Union, the profession of nurse is regulated. A profession is said to be regulated when access and exercise is subject to the possession of a specific professional qualification. The regulated professions database contains

a list of regulated professions for nurse in the European Union member states, European Economic Area countries, and Switzerland. This list is covered by the Directive 2005/36/EC. Asia India Nursing education is governed in India by the central body Indian Nursing Council and its norms are implemented through respective State Nursing council such as Kerala Nurses and Midwives Council.

Indian Nursing Council Act, 1947. Act Year Number: Act No. 19 of December enactment Date of enactment: Act Objective: An Act to constitute the Nursing Council of India. To establish uniform standards of training for nurses, midwives, and health visitors. It is implemented with 17 sections and each section indicates the specific legislative role of the council.

Iran See Nursing in Iran.

Israel Nurses in Israel have a wide variety of responsibilities, including hospital care, patient education, wound care, prenatal and other monitoring, midwifery, and well-baby clinics.

Nursing in Israeli culture begins with Shifra and Puah, the two Jewish midwives who helped the Jewish women in ancient Egypt give birth.

Modern-day nursing was established with through the nurses sent to Israel by the Hadassah organization, as well as a nursing school founded by Henrietta Szold in 1918. During those times, the United Kingdom regulated midwifery in Israel, but the nurses were not mentioned in the regulation decree.

Today, nurses and midwives are regulated through the Israeli Ministry of Health.

Japan History Nursing was not an established part of Japan's healthcare system until 1899 with the Midwives Ordinance. From there the Registered Nurse Ordinance came into play in 1915. This established a legal substantiation to registered nurses all over Japan. A new law geared towards nurses was created during World War II: the Public Health Nurse, Midwife and Nurse Law, established in 1948. On average, Japanese nurses make around 280,000 yen a month, and it is one of the higher paying jobs. However, physicians make twice as much as nurses. Similar to other cultures, the Japanese people view nurses as subservient to physicians. According to the American Nurses Association article on Japan, "nursing work has been described using negative terminology such as 'hard, dirty, dangerous, low salary, few holidays, minimal chance of marriage and family, and poor image.'"

There are organizations that unite Japanese nurses like the Japanese Nursing Association ; the JNA is a professional organization and not a union. Members of the JNA lobby politicians and produces publications about nursing. According to the American Nurses Association's article on Japan, the JNA "works toward the improvement in nursing practice through many activities including the development of a policy research group to influence policy development, a code of ethics for nurses, and standards of nursing practice." The JNA also provides certification for specialists in mental health,

oncology and community health. The Taiwan Union of Nurses Association is the union unit in Taiwan, fighting for nurses on payment and working time issues.

Australia Catholic religious institutes were influential in the development of Australian nursing, founding many of Australia's hospitals – the Irish Sisters of Charity were first to arrive in 1838 and established St Vincent's Hospital, Sydney in 1857 as a free hospital for the poor. They and other orders like the Sisters of Mercy, and in aged care the Sisters of the Little Company of Mary and Little Sisters of the Poor founded hospitals, hospices, research institutes and aged care facilities around Australia.

A census in the 1800s found several hundred nurses working in Western Australia during the colonial period of history, this included Aboriginal female servants who cared for the infirm.

The state nursing licensing bodies amalgamated in Australia in 2011 under the federal body AHPRA . Several divisions of nursing license is available and recognized around the country.

Enrolled nurses may initiate some oral medication orders with a specific competency now included in national curricula but variable in application by agency.

Registered nurses hold a university degree .

Nurse practitioners have started emerging from postgraduate programs and work in both private practice and public hospitals and clinics.

Mental health nurses must complete further training as advanced mental health practitioners in order to administer client referrals under the Mental Health Act. Australia enjoys the luxury of a national curriculum for vocational nurses, trained at Technical and Further Education colleges or private Registered Training Organization . Enrolled and registered nurses are identified by the department of immigration as an occupational area of need, although registered nurses are always in shorter supply, and this increases in proportion with specialization.

In 1986 there were a number of rolling industrial actions around the country, culminating when five thousand Victorian nurses went on strike for eighteen days. The hospitals were able to function by hiring casual staff from each other's striking members, but the increased cost forced a decision in the nurses' favor.

See also Advanced practice registered nurse Deaconess Emergency nursing History of hospitals History of medicine History of nursing History of Nursing in the United Kingdom

History of nursing in the United States History of Philippine nurses in the United States Index of nursing articles Licensed practical nurse List of nurses List of nursing specialties Men in nursing Nightingale Pledge Nurse uniform Nurse–client relationship Nurse scheduling problem Nursing care plan Nursing ethics Nursing in Australia Nursing in Germany Nursing in Hong Kong Nursing in India Nursing in Islam Nursing in Japan Nursing in Kenya Nursing in Pakistan Nursing in Taiwan Nursing in the Philippines Nursing in the United States Nursing school Nurse stereotypes Nursing theory Registered nurse

Transcultural nursing Wet nurse References Bibliography Further reading Advanced Practice and Leadership in Radiology Nursing. Springer Publishing. .

Longe, Jacqueline, ed. Gale Encyclopedia of Nursing and Allied Health Historical Bullough, Vern L. and Bonnie Bullough. The Emergence of Modern Nursing D'Antonio, Patricia. American Nursing: A History of Knowledge, Authority, and the Meaning of Work, 272pp.

Dock, Lavinia Lloyd. A Short history of nursing from the earliest times to the present day ; abbreviated version of her four volume A History of Nursing Donahue, M. Patricia. Nursing, The Finest Art: An Illustrated History, includes over 400 illustrations; 416pp; Fairman, Julie and Joan E. Lynaugh. Critical Care Nursing: A History Judd, Deborah. A History of American Nursing: Trends and Eras 272pp Kalisch, Philip A., and Beatrice J. Kalisch. Advance of American Nursing ; 4th ed 2003 is titled, American Nursing: A History Snodgrass, Mary Ellen. Historical Encyclopedia of Nursing, 354pp; from ancient times to the present.

OrthopedicsOrthopedics surgery or orthopedics is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal trauma, spine diseases, sports injuries, degenerative diseases, infections, tumors, and congenital disorders.

Etymology Nicholas Andry coined the word in French as '', derived from the Ancient Greek words ὀρθόσ orthos and παιδίον paidion, and published Orthopedie in 1741. The word was assimilated into English as orthopædics; the ligature æ was common in that era for ae'' in Greek- and Latin-based words. As the name implies, the discipline was initially developed with attention to children, but the correction of spinal and bone deformities in all stages of life eventually became the cornerstone of orthopedic practice.

Differences in spelling As with many words derived with the "æ" ligature, simplification to either "ae" or just "e" is common, especially in North America. In the US, the majority of college, university, and residency programmes, and even the American Academy of Orthopaedic Surgeons, still use the spelling with the digraph ae, though hospitals usually use the shortened form.

Elsewhere, usage is not uniform; in Canada, both spellings are acceptable; "orthopaedics" usually prevails in the rest of the British Commonwealth, especially in the UK. However, arguing that orthopedics are not limited to the treatment of children, and - and even more importantlypresenting the linguistic justification for the derivation of the term from the ancient Greek term orthopodeo rather than from the misleadingly introduced usage of «paed-ion» by Andry, the Greek orthopaedic surgeon Nikolaos Christodoulou rejects the literal meaning of orthopaedic as "straight-childish" and urges "the unanimous acceptance and adoption...... of the term ortho-ped-ics .." which maintains the original Ancient Greek root".

Jean-André Venel established the first orthopedic institute in 1780, which was the first hospital dedicated to the treatment of children's skeletal deformities. He developed the club-foot shoe for children born with foot deformities and various methods to treat curvature of the spine.

Advances made in surgical technique during the 18th century, such as John Hunter's research on tendon healing and Percival Pott's work on spinal deformity steadily increased the range of new methods available for effective treatment.

Antonius Mathijsen, a Dutch military surgeon, invented the plaster of Paris cast in 1851. Until the 1890s, though, orthopedics was still a study limited to the correction of deformity in children. One of the first surgical procedures developed was percutaneous tenotomy. This involved cutting a tendon, originally the Achilles tendon, to help treat deformities alongside bracing and exercises. In the late 1800s and first decades of the 1900s, significant controversy arose about whether orthopedics should include surgical procedures at all. Thomas became interested in orthopedics and bone-setting at a young age, and after establishing his own practice, went on to expand the field into the general treatment of fracture and other musculoskeletal problems. He advocated enforced rest as the best remedy for fractures and tuberculosis, and created the so-called "Thomas splint" to stabilize a fractured femur and prevent infection. He is also responsible for numerous other medical innovations that all carry his name: Thomas's collar to treat tuberculosis of the cervical spine, Thomas's manoeuvre, an orthopedic investigation for fracture of the hip joint, the Thomas test, a method of detecting hip deformity by having the patient lying flat in bed, and Thomas's wrench for reducing fractures, as well as an osteoclast to break and reset bones.

Thomas's work was not fully appreciated in his own lifetime. Only during the First World War did his techniques come to be used for injured soldiers on the battlefield. His nephew, Sir Robert Jones, had already made great advances in

orthopedics in his position as surgeon-superintendent for the construction of the Manchester Ship Canal in 1888. He was responsible for the injured among the 20,000 workers, and he organized the first comprehensive accident service in the world, dividing the 36-mile site into three sections, and establishing a hospital and a string of first-aid posts in each section. He had the medical personnel trained in fracture management. He personally managed 3,000 cases and performed 300 operations in his own hospital. This position enabled him to learn new techniques and improve the standard of fracture management. Physicians from around the world came to Jones’ clinic to learn his techniques. Along with Alfred Tubby, Jones founded the British Orthopaedic Society in 1894.

During the First World War, Jones served as a Territorial Army surgeon. He observed that treatment of fractures both, at the front and in hospitals at home, was inadequate, and his efforts led to the introduction of military orthopedic hospitals. He was appointed Inspector of Military Orthopaedics, with responsibility for 30,000 beds. The hospital in Duncan Road, Hammersmith, became the model for both British and American military orthopedic hospitals. His advocacy of the use of Thomas splint for the initial treatment of femoral fractures reduced mortality of compound fractures of the femur from 87% to less than 8% in the period from 1916 to 1918.

The use of intramedullary rods to treat fractures of the femur and tibia was pioneered by Gerhard Küntscher of Germany. This made a noticeable difference to the speed of recovery of injured German soldiers during World War II and led to more widespread adoption of intramedullary fixation of fractures in the rest of the world. Traction was the standard method of treating thigh bone fractures until the late 1970s, though, when the Harborview Medical Center group in Seattle popularized intramedullary fixation without opening up the fracture.

The modern total hip replacement was pioneered by Sir John Charnley, expert in tribology at Wrightington Hospital, on England in the 1960s. He found that joint surfaces could be replaced by implants cemented to the bone. His design consisted of a stainless steel, one-piece femoral stem and head, and a polyethylene acetabular component, both of which were fixed to the bone using PMMA bone cement. For over two decades, the Charnley low-friction arthroplasty and its derivative designs were the most-used systems in the world. This formed the basis for all modern hip implants.

The Exeter hip replacement system was developed at the same time. Since Charnley, improvements have been continuous in the design and technique of joint replacement with many contributors, including W. H. Harris, the son of R. I. Harris, whose team at Harvard pioneered uncemented arthroplasty techniques with the bone bonding directly to the implant.

Knee replacements, using similar technology, were started by McIntosh in rheumatoid arthritis patients and later by Gunston and Marmor for osteoarthritis in the 1970s, developed by Dr. John Insall in New York using a fixed bearing system, and by Dr. Frederick Buechel and Dr. Michael Pappas using a mobile bearing system.

External fixation of fractures was refined by American surgeons during the Vietnam War, but a major contribution was made by Gavril Abramovich Ilizarov in the USSR. He was sent, without much orthopedic training, to look after injured Russian soldiers in Siberia in the 1950s. With no equipment, he was confronted with crippling conditions of unhealed, infected, and misaligned fractures. With the help of the local bicycle shop, he devised ring external fixators tensioned like the spokes of a bicycle. With this equipment, he achieved healing, realignment, and lengthening to a degree unheard of elsewhere. His Ilizarov apparatus is still used today as one of the distraction osteogenesis methods.

Modern orthopedic surgery and musculoskeletal research have sought to make surgery less invasive and to make implanted components better and more durable. On the other hand, since the emergence of the opioid epidemic, Orthopedic Surgeons have been identified as one of the highest prescribers of opioid medications. The future of Orthopedic Surgery will likely focus on finding ways for the profession to decrease prescription of opioids while still providing adequate pain control for patients. According to the latest Occupational Outlook Handbook published by the United States Department of Labor, 3 to 4% of all practicing physicians are orthopedic surgeons.

Many orthopedic surgeons elect to do further training, or fellowships, after completing their residency training.

Fellowship training in an orthopedic sub-specialty is typically one year in duration and sometimes has a research component involved with the clinical and operative training. Examples of orthopedic subspecialty training in the United States are: Hand and upper extremity Shoulder and elbow Total joint reconstruction Pediatric orthopedics Foot and ankle surgery Spine surgery Orthopedic oncologist Surgical sports medicine Orthopedic trauma Hip and Knee surgery Osseointegration These specialised areas of medicine are not exclusive to orthopedic surgery. For example, hand surgery is practiced by some plastic surgeons, and spine surgery is practiced by most neurosurgeons. Additionally, some aspects of foot and ankle surgery are also practiced by board-certified doctors of podiatric medicine in the United States. Some family practice physicians practice sports medicine, but their scope of practice is no operative.

After completion of specialty residency/registrar training, an orthopedic surgeon is then eligible for board certification by the American Board of Medical Specialties or the American Osteopathic Association Bureau of Osteopathic Specialists. Certification by the American Board of Orthopaedic Surgery or the American Osteopathic Board of Orthopedic Surgery means that the orthopedic surgeon has met the specified educational, evaluation, and examination requirements of the board. The process requires successful completion of a standardized written examination followed by an oral examination focused on the surgeon's clinical and surgical performance over a 6-month period. In Canada, the certifying organization is the Royal College of Physicians and Surgeons of Canada; in Australia and New Zealand, it is the Royal Australasian College of Surgeons.

In the United States, specialists in hand surgery and orthopedic sports medicine may obtain a certificate of added qualifications in addition to their board primary certification by successfully completing a separate standardized examination. No additional certification process exists for the other subspecialties.

Practice According to applications for board certification from 1999 to 2003, the top 25 most common procedures performed by orthopedic surgeons are: # Knee arthroscopy and meniscectomy # Shoulder arthroscopy and decompression

# Carpal tunnel release # Knee arthroscopy and chondroplasty # Removal of support implant # Knee arthroscopy and anterior cruciate ligament reconstruction # Knee replacement # Repair of femoral neck fracture # Repair of trochanteric fracture # Debridement of skin/muscle/bone/ fracture # Knee arthroscopy repair of both menisci # Hip replacement # Shoulder arthroscopy/distal clavicle excision # Repair of rotator cuff tendon # Repair fracture of radius /ulna # Laminectomy # Repair of ankle fracture # Shoulder arthroscopy and debridement # Lumbar spinal fusion # Repair fracture of the distal part of radius # Low back intervertebral disc surgery # incise finger tendon sheath # Repair of ankle fracture # Repair of femoral shaft fracture # Repair of trochanteric fracture A typical schedule for a practicing orthopedic surgeon involves 50–55 hours of work per week divided among clinic, surgery, various administrative duties, and possibly teaching and/or research if in an academic setting.

Arthroscopy The use of arthroscopic techniques has been particularly important for injured patients. Arthroscopy was pioneered in the early 1950s by Dr. Masaki Watanabe of Japan to perform minimally invasive cartilage surgery and reconstructions of torn ligaments. Arthroscopy allows patients to recover from the surgery in a matter of days, rather than the weeks to months required by conventional, "open" surgery; it is a very popular technique. Knee arthroscopy is one of the most

common operations performed by orthopedic surgeons today, and is often combined with meniscectomy or chondroplasty. The majority of upper-extremity outpatient orthopedic procedures are now performed arthroscopically.

Arthroplasty Arthroplasty is an orthopedic surgery where the articular surface of a musculoskeletal joint is replaced, remodeled, or realigned by osteotomy or some other procedure. It is an elective procedure that is done to relieve pain and restore function to the joint after damage by arthritis or some other type of trauma. As well as the standard total knee replacement surgery, the uni-compartmental knee replacement, in which only one weight-bearing surface of an arthritic knee is replaced, is a popular alternative.

Joint replacements are available for other joints on a variable basis, most notably the hip, shoulder, elbow, wrist, ankle, spine, and finger joints.

In recent years, surface replacement of joints, in particular the hip joint, has become more popular amongst younger and more active patients. This type of operation delays the need for the more traditional and less bone-conserving total hip replacement, but carries significant risks of early failure from fracture and bone death.

One of the main problems with joint replacements is wear of the bearing surfaces of components. This can lead to damage to the surrounding bone and contribute to eventual failure of the implant. The use of alternative bearing surfaces has increased in recent years, particularly in younger patients, in an attempt to improve the wear characteristics of joint replacement components. These include ceramics and all-metal implants. The plastic chosen is usually ultra-high-molecular-weight polyethylene, which can also be altered in ways that may improve wear characteristics.

Epidemiology Between 2001 and 2016, the prevalence of musculoskeletal procedures drastically increased in the U.S, from 17.9% to 24.2% of all operating-room procedures performed during hospital stays.

In a study of hospitalizations in the United States in 2012, spine and joint procedures were common among all age groups except infants. Spinal fusion was one of the five most common OR procedures performed in every age group except infants younger than 1 year and adults 85 years and older. Laminectomy was common among adults aged 18–84 years. Knee arthroplasty and hip replacement were in the top five OR procedures for adults aged 45 years and older.

See also Outline of trauma and orthopedics Index of trauma and orthopaedics articles Bone grafting Orthotics List of orthopedic implants.

PathologyPathology is the study of the causes and effects of disease or injury. The word pathology also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in the context of modern medical treatment, the term is often used in a more narrow fashion to refer to processes and tests which fall within the contemporary medical field of "general pathology", an area which includes a number of distinct but inter-related medical specialties that diagnose disease, mostly through analysis of tissue, cell, and body fluid samples. Idiomatically, pathology" may also refer to the predicted or actual progression of particular diseases, and the affix pathy is sometimes used to indicate a state of disease in cases of both physical ailment and psychological conditions. A physician practicing pathology is called a pathologist.

As a field of general inquiry and research, pathology addresses components of disease: cause, mechanisms of development, structural alterations of cells, and the consequences of changes. In common medical practice, general pathology is mostly concerned with analyzing known clinical abnormalities that are markers or precursors for both infectious and non-infectious disease, and is conducted by experts in one of two major specialties, anatomical pathology and clinical pathology. Further divisions in specialty exist on the basis of the involved sample types, organs, and physiological systems, as well as on the basis of the focus of the examination.

Pathology is a significant field in modern medical diagnosis and medical research.

History The study of pathology, including the detailed examination of the body, including dissection and inquiry into specific maladies, dates back to antiquity. Rudimentary understanding of many conditions was present in most early societies and is attested to in the records of the earliest historical societies, including those of the Middle East, India, and China.

By the Hellenic period of ancient Greece, a concerted causal study of disease was underway, with many notable early physicians having developed methods of diagnosis and prognosis for a number of diseases. The medical practices of the Romans and those of the Byzantines continued from these Greek roots, but, as with many areas of scientific inquiry, growth in understanding of medicine stagnated some after the Classical Era, but continued to slowly develop throughout numerous cultures. Notably, many advances were made in the medieval era of Islam, during which numerous texts of complex pathologies were developed, also based on the Greek tradition. Even so, growth in complex understanding of disease mostly languished until knowledge and experimentation again began to proliferate in the Renaissance, Enlightenment, and Baroque eras, following the resurgence of the empirical method at new centers of scholarship. By the 17th century, the study of rudimentary microscopy was underway and examination of tissues had led British Royal Society member Robert Hooke to coin the word "cell", setting the stage for later germ theory.

Modern pathology began to develop as a distinct field of inquiry during the 19th Century through natural philosophers and physicians that studied disease and the informal study of what they termed “pathological anatomy” or “morbid anatomy”. However, pathology as a formal area of specialty was not fully developed until the late 19th and early 20th centuries, with the advent of detailed study of microbiology. In the 19th century, physicians had begun to understand that disease-causing pathogens, or "germs” existed and were capable of reproduction and multiplication, replacing earlier beliefs in humors or even spiritual agents, that had dominated for much of the previous 1,500 years in European medicine. With the new understanding of causative agents, physicians began to compare the characteristics of one germ's symptoms as they developed within an affected individual to another germ's characteristics and symptoms. This approach led to the foundational understanding that diseases are able to replicate themselves, and that they can have many profound and varied effects on the human host. To determine causes of diseases, medical experts used the most common and widely accepted assumptions or symptoms of their times, a general principal of approach that persists into modern medicine.

Modern medicine was particularly advanced by further developments of the microscope to analyze tissues, to which Rudolf Virchow gave a significant contribution, leading to a slew of research developments.

By the late 1920s to early 1930s pathology was deemed a medical specialty. Combined with developments in the understanding of general physiology, by the beginning of the 20th century, the study of pathology had begun to split into a number of distinct fields, resulting in the development of a large number of modern specialties within pathology and related disciplines of diagnostic medicine.

Etymology The terms pathology comes from the Ancient Greek roots of pathos, meaning "experience" or "suffering" and -logia, "study of".

General pathology The modern practice of pathology is divided into a number of subdisciplines within the discrete but deeply interconnected aims of biological research and medical practice. Biomedical research into disease incorporates the work of a vast variety of life science specialists, whereas, in most parts of the world, to be licensed to practice pathology as a medical specialty, one has to complete medical school and secure a license to practice medicine. Structurally, the study of disease is divided into many different fields that study or diagnose markers for disease using methods and technologies particular to specific scales, organs, and tissue types. The information in this section mostly concerns pathology as it regards common medical practice in these systems, but each of these specialties is also the subject of voluminous pathology research as regards the disease pathways of specific pathogens and disorders that affect the tissues of these discrete organs or structures. .

Anatomical pathology Anatomical pathology or anatomic pathology is a medical specialty that is concerned with the diagnosis of disease based on the gross, microscopic, chemical, immunologic and molecular examination of organs, tissues, and whole bodies.

Anatomical pathology is itself divided into subfields, the main divisions being surgical pathology, cytopathology, and forensic pathology. Anatomical pathology is one of two main divisions of the medical practice of pathology, the other being clinical pathology, the diagnosis of disease through the laboratory analysis of bodily fluids and tissues. Sometimes, pathologists practice both anatomical and clinical pathology, a combination known as general pathology.

Cytopathology Cytopathology is a branch of pathology that studies and diagnoses diseases on the cellular level. It is usually used to aid in the diagnosis of cancer, but also helps in the diagnosis of certain infectious diseases and other inflammatory conditions as well as thyroid lesions, diseases involving sterile body cavities, and a wide range of other body sites.

Cytopathology is generally used on samples of free cells or tissue fragments and cytopathology tests are sometimes called smear tests because the samples may be smeared across a glass microscope slide for subsequent staining and microscopic examination. However, cytology samples may be prepared in other ways, including cytocentrifugation.

Dermatopathology Dermatopathology is a subspecialty of anatomic pathology that focuses on the skin and the rest of the integumentary system as an organ. It is unique, in that there are two paths a physician can take to obtain the specialization. All general pathologists and general dermatologists train in the pathology of the skin, so the term dermatopathologist denotes either of these who has reached a certainly level of accreditation and experience; in the US, either a general pathologist or a dermatologist can undergo a 1 to 2 year fellowship in the field of dermatopathology. The completion of this

fellowship allows one to take a subspecialty board examination, and becomes a board certified dermatopathologist.

Dermatologists are able to recognize most skin diseases based on their appearances, anatomic distributions, and behavior. Sometimes, however, those criteria do not lead to a conclusive diagnosis, and a skin biopsy is taken to be examined under the microscope using usual histological tests. In some cases, additional specialized testing needs to be performed on biopsies, including immunofluorescence, immunohistochemistry, electron microscopy, flow cytometry, and molecular-pathologic analysis. One of the greatest challenges of dermatopathology is its scope. More than 1500 different disorders of the skin exist, including cutaneous eruptions and neoplasms. Therefore, dermatopathologists must maintain a broad base of knowledge in clinical dermatology, and be familiar with several other specialty areas in Medicine.

Forensic pathology Forensic pathology focuses on determining the cause of death by post-mortem examination of a corpse or partial remains. An autopsy is typically performed by a coroner or medical examiner, often during criminal investigations; in this role, coroners and medical examiners are also frequently asked to confirm the identity of a corpse. The requirements for becoming a licensed practitioner of forensic pathology varies from country to country but typically a minimal requirement is a medical doctorate with a specialty in general or anatomical pathology with subsequent study in forensic medicine. The methods forensic scientists use to determine death include examination of tissue specimens to identify the presence or absence of natural disease and other microscopic findings, interpretations of toxicology on body tissues and fluids to determine the chemical cause of overdoses, poisonings or other cases involving toxic agents, and examinations of physical trauma. Forensic pathology is a major component in the trans-disciplinary field of forensic science.

Histopathology Histopathology refers to the microscopic examination of various forms of human tissue. Specifically, in clinical medicine, histopathology refers to the examination of a biopsy or surgical specimen by a pathologist, after the specimen has been processed and histological sections have been placed onto glass slides. This contrasts with the methods of cytopathology, which uses free cells or tissue fragments. Histopathological examination of tissues starts with surgery, biopsy, or autopsy. The tissue is removed from the body of an organism and then placed in a fixative that stabilizes the tissues to prevent decay. The most common fixative is formalin, although frozen section fixing is also common. To see the tissue under a microscope, the sections are stained with one or more pigments. The aim of staining is to reveal cellular components; counterstains are used to provide contrast. Histochemistry refers to the science of using chemical reactions between laboratory chemicals and components within tissue. The histological slides are then interpreted diagnostically and the resulting pathology report describes the histological findings and the opinion of the pathologist. In the case of cancer, this represents the tissue diagnosis required for most treatment protocols.

Neuropathology Neuropathology is the study of disease of nervous system tissue, usually in the form of either surgical biopsies or sometimes whole brains in the case of autopsy. Neuropathology is a subspecialty of anatomic pathology, neurology, and neurosurgery. In many English-speaking countries, neuropathology is considered a subfield of anatomical pathology. A physician, who specializes in neuropathology, usually by completing a fellowship after a residency in anatomical or general pathology, is called a neuropathology’s. In day-to-day clinical practice, a neuropathologist is a consultant for other physicians. If a disease of the nervous system is suspected, and the diagnosis cannot be made by less invasive methods, a biopsy of nervous tissue is taken from the brain or spinal cord to aid in diagnosis. Biopsy is usually requested after a mass is detected by medical imaging. With autopsies, the principal work of the neuropathologist is to help in the post-mortem diagnosis of various conditions that affect the central nervous system. Biopsies can also consist of the skin.

Epidermal nerve fiber density testing is a more recently developed neuropathology test in which a punch skin biopsy is taken to identify small fiber neuropathies by analyzing the nerve fibers of the skin. This test is becoming available in select labs as well as many universities; it replaces the traditional nerve biopsy test as less invasive.

Pulmonary pathology Pulmonary pathology is a subspecialty of anatomic pathology that deals with diagnosis and characterization of neoplastic and non-neoplastic diseases of the lungs and thoracic pleura. Diagnostic specimens are often obtained via bronchoscopic transbronchial biopsy, CT-guided percutaneous biopsy, or video-assisted thoracic surgery. These tests can be necessary to diagnose between infection, inflammation, or fibrotic conditions.

Renal pathology Renal pathology is a subspecialty of anatomic pathology that deals with the diagnosis and characterization of disease of the kidneys. In a medical setting, renal pathologists work closely with nephrologists and transplant surgeons, who typically obtain diagnostic specimens via percutaneous renal biopsy. The renal pathologist must synthesize findings from traditional microscope histology, electron microscopy, and immunofluorescence to obtain a definitive diagnosis. Medical renal diseases may affect the glomerulus, the tubules and interstitium, the vessels, or a combination of these compartments.

Surgical pathology Surgical pathology is one of the primary areas of practice for most anatomical pathologists. Surgical pathology involves the gross and microscopic examination of surgical specimens, as well as biopsies submitted by surgeons and nonsurgeons such as general internists, medical subspecialists, dermatologists, and interventional radiologists. Often an excised tissue sample is the best and most definitive evidence of disease in cases where tissue is surgically removed from a patient. These determinations are usually accomplished by a combination of gross and histologic examination of the tissue, and may involve evaluations of molecular properties of the tissue by immunohistochemistry or other laboratory tests.

There are two major types of specimens submitted for surgical pathology analysis: biopsies and surgical resections. A biopsy is a small piece of tissue removed primarily for surgical pathology analysis, most often in order to render a definitive diagnosis. Types of biopsies include core biopsies, which are obtained through the use of large-bore needles, sometimes under the guidance of radiological techniques such as ultrasound, CT scan, or magnetic resonance imaging.

Incisional biopsies are obtained through diagnostic surgical procedures that remove part of a suspicious lesion, whereas excisional biopsies remove the entire lesion, and are similar to therapeutic surgical resections. Excisional biopsies of skin lesions and gastrointestinal polyps are very common. The pathologist's interpretation of a biopsy is critical to establishing the diagnosis of a benign or malignant tumor, and can differentiate between different types and grades of cancer, as well as determining the activity of specific molecular pathways in the tumor. Surgical resection specimens are obtained by the therapeutic surgical removal of an entire diseased area or organ. These procedures are often intended as definitive surgical treatment of a disease in which the diagnosis is already known or strongly suspected, but pathological analysis of these specimens remains important in confirming the previous diagnosis.

Clinical pathology Clinical pathology is a medical specialty that is concerned with the diagnosis of disease based on the laboratory analysis of bodily fluids such as blood and urine, as well as tissues, using the tools of chemistry, clinical microbiology, hematology and molecular pathology. Clinical pathologists work in close collaboration with medical technologists, hospital administrations, and referring physicians. Clinical pathologists learn to administer a number of visual and microscopic

tests and an especially large variety of tests of the biophysical properties of tissue samples involving automated analysers and cultures. Sometimes the general term "laboratory medicine specialist" is used to refer to those working in clinical pathology, including medical doctors, Ph.D.s and doctors of pharmacology. Immunopathology, the study of an organism's immune response to infection, is sometimes considered to fall within the domain of clinical pathology.

Hematopathology Hematopathology is the study of diseases of blood cells and the tissues, and organs comprising the hematopoietic system. The term hematopoietic system refers to tissues and organs that produce and/or primarily host hematopoietic cells and includes bone marrow, the lymph nodes, thymus, spleen, and other lymphoid tissues. In the United States, hematopathology is a board certified subspecialty practiced by those physicians who have completed a general pathology residency and an additional year of fellowship training in hematology. The hematopathologist reviews biopsies of lymph nodes, bone marrows and other tissues involved by an infiltrate of cells of the hematopoietic system. In addition, the hematopathologist may be in charge of flow cytometric and/or molecular hematopathology studies.

Molecular pathology Molecular pathology is focused upon the study and diagnosis of disease through the examination of molecules within organs, tissues or bodily fluids. Molecular pathology is multidisciplinary by nature and shares some aspects of practice with both anatomic pathology and clinical pathology, molecular biology, biochemistry, proteomics and genetics. It is often applied in a context that is as much scientific as directly medical and encompasses the development of molecular and genetic approaches to the diagnosis and classification of human diseases, the design and validation of predictive biomarkers for treatment response and disease progression, and the susceptibility of individuals of different genetic constitution to particular disorders. The crossover between molecular pathology and epidemiology is represented by a related field "molecular pathological epidemiology". Molecular pathology is commonly used in diagnosis of cancer and infectious diseases. Molecular Pathology is primarily used to detect cancers such as melanoma, brainstem glioma, brain tumors as well as many other types of cancer and infectious diseases. Techniques are numerous but include quantitative polymerase chain reaction, multiplex PCR, DNA microarray, in situ hybridization, DNA sequencing, antibody-based immunofluorescence tissue assays, molecular profiling of pathogens, and analysis of bacterial genes for antimicrobial resistance. Techniques used are based on analyzing samples of DNA and RNA. Pathology is widely used for gene therapy and disease diagnosis.

Oral and maxillofacial pathology Oral and Maxillofacial Pathology is one of nine dental specialties recognized by the American Dental Association, and is sometimes considered a specialty of both dentistry and pathology. Oral Pathologists must complete three years of post doctoral training in an accredited program and subsequently obtain diplomate status from the American Board of Oral and Maxillofacial Pathology. The specialty focuses on the diagnosis, clinical management and investigation of diseases that affect the oral cavity and surrounding maxillofacial structures including but not limited to odontogenic, infectious, epithelial, salivary gland, bone and soft tissue pathologies. It also significantly intersects with the field of dental pathology. Although concerned with a broad variety of diseases of the oral cavity, they have roles distinct from otorhinolaryngologists, and speech pathologists, the latter of which helps diagnose many neurological or neuromuscular conditions relevant to speech phonology or swallowing. Owing to the availability of the oral cavity to non-invasive examination, many conditions in the study of oral disease can be diagnosed, or at least suspected, from gross examination, but biopsies, cell smears, and other tissue analysis remain important diagnostic tools in oral pathology.

Medical training and accreditation

Becoming a pathologist generally requires specialty-training after medical school, but individual nations vary some in the medical licensing required of pathologists. In the United States, pathologists are physicians who have completed a fouryear undergraduate program, four years of medical school training, and three to four years of postgraduate training in the form of a pathology residency. Training may be within two primary specialties, as recognized by the American Board of Pathology: anatomical pathology and clinical Pathology, each of which requires separate board certification. The American Osteopathic Board of Pathology also recognizes four primary specialties: anatomic pathology, dermatopathology, forensic pathology, and laboratory medicine. Pathologists may pursue specialised fellowship training within one or more subspecialties of either anatomical or clinical pathology. Some of these subspecialties permit additional board certification, while others do not.

In the United Kingdom, pathologists are physicians licensed by the UK General Medical Council. The training to become a pathologist is under the oversight of the Royal College of Pathologists. After four to six years of undergraduate medical study, trainees proceed to a two-year foundation program. Full-time training in histopathology currently lasts between five and five and a half years and includes specialist training in surgical pathology, cytopathology, and autopsy pathology. It is also possible to take a Royal College of Pathologists diploma in forensic pathology, dermatopathology, or cytopathology, recognising additional specialist training and expertise and to get specialist accreditation in forensic pathology, pediatric pathology, and neuropathology. All postgraduate medical training and education in the UK is overseen by the General Medical Council.

In France, pathology is separated into two distinct specialties, anatomical pathology, and clinical pathology. Residencies for both lasts four years. Residency in anatomical pathology is open to physicians only, while clinical pathology is open to both physicians and pharmacists. At the end of the second year of clinical pathology residency, residents can choose between general clinical pathology and a specialization in one of the disciplines, but they can not practice anatomical pathology, nor can anatomical pathology residents practice clinical pathology.

Overlap with other diagnostic medicine Though separate fields in terms of medical practice, a number of areas of inquiry in medicine and medical science either overlap greatly with general pathology, work in tandem with it, or contribute significantly to the understanding of the pathology of a given disease or its course in an individual. As a significant portion of all general pathology practice is concerned with cancer, the practice of oncology makes extensive use of both anatomical and clinical pathology in diagnosis and treatment. In particular, biopsy, resection, and blood tests are all examples of pathology work that is essential for the diagnoses of many kinds of cancer and for the staging of cancerous masses. In a similar fashion, the tissue and blood analysis techniques of general pathology are of central significance to the investigation of serious infectious disease and as such inform significantly upon the fields of epidemiology, etiology, immunology, and parasitology. General pathology methods are of great importance to biomedical research into disease, wherein they are sometimes referred to as "experimental" or "investigative" pathology.

Medical imaging is the generating of visual representations of the interior of a body for clinical analysis and medical intervention. Medical imaging reveals details of internal physiology that help medical professionals plan appropriate treatments for tissue infection and trauma. Medical imaging is also central in supplying the biometric data necessary to establish baseline features of anatomy and physiology so as to increase the accuracy with which early or fine-detail abnormalities are detected. These diagnostic techniques are often performed in combination with general pathology procedures and are themselves often essential to developing new understanding of the pathogenesis of a given disease and tracking the progress of disease in specific medical cases. Examples of important subdivisions in medical imaging include radiology magnetic resonance imaging, medical ultrasonography, endoscopy, elastography, tactile imaging, thermography, medical photography, nuclear medicine and functional imaging techniques such as positron emission

tomography. Though they do not strictly relay images, readings from diagnostics tests involving electroencephalography, magneto encephalography, and electrocardiography often give hints as to the state and function of certain tissues in the brain and heart respectively.

Psychopathology Psychopathology is the study of mental illness, particularly of severe disorders. Informed heavily by both psychology and neurology, its purpose is to classify mental illness, elucidate its underlying causes, and guide clinical psychiatric treatment accordingly. Although diagnosis and classification of mental norms and disorders is largely the purview of psychiatry—the results of which are guidelines such as the Diagnostic and Statistical Manual of Mental Disorders, which attempt to classify mental disease mostly on behavioral evidence, though not without controversy—the field is also heavily, and increasingly, informed upon by neuroscience and other of the biological cognitive sciences. Mental or social disorders or behaviors seen as generally unhealthy or excessive in a given individual, to the point where they cause harm or severe disruption to the sufferer's lifestyle, are often called "pathological" .

Non-humans Although the vast majority of lab work and research in pathology concerns the development of disease in humans, pathology is of significance throughout the biological sciences. Two main catch-all fields exist to represent most complex organisms capable of serving as host to a pathogen or other form of disease: veterinary pathology and phytopathology, which studies disease in plants.

Veterinary pathology Veterinary pathology covers a vast array of species, but with a significantly smaller number of practitioners, so understanding of disease in non-human animals, especially as regards veterinary practice, varies considerably by species.

Nonetheless, significant amounts of pathology research are conducted on animals, for two primary reasons: 1) The origins of diseases are typically zoonotic in nature, and many infectious pathogens have animal vectors and, as such, understanding the mechanisms of action for these pathogens in non-human hosts is essential to the understanding and application of epidemiology and 2) those animals that share physiological and genetic traits with humans can be used as surrogates for the study of the disease and potential treatments as well as the effects of various synthetic products. For this reason, as well as their roles as livestock and companion animals, mammals generally have the largest body of research in veterinary pathology. Animal testing remains a controversial practice, even in cases where it is used to research treatment for human disease. As in human medical pathology, the practice of veterinary pathology is customarily divided into the two main fields of anatomical and clinical pathology.

Plant pathology Although the pathogens and their mechanics differ greatly from those of animals, plants are subject to a wide variety of diseases, including those caused by fungi, oomycetes, bacteria, viruses, viroids, virus-like organisms, phytoplasmas, protozoa, nematodes and parasitic plants. Damage caused by insects, mites, vertebrate, and other small herbivores is not considered a part of the domain of plant pathology. The field is connected to plant disease epidemiology and especially concerned with the horticulture of species that are of high importance to the human diet or other human utility.

See also Biopsy Causal inference

Cell Disease Environmental pathology Epidemiology Etiology Hematology Histology Immunology List of pathologists Medical diagnosis Medical jurisprudence Medicine Microbiology Micrograph Microscopy Minimally-invasive procedures Oncology Parasitology Pathogen Pathogenesis Pathophysiology Precision medicine Spectroscopy Speech–language pathology Telepath ology.

PharmacyPharmacy is the clinical health science that links medical science with chemistry and it is charged with the discovery, production, disposal, safe and effective use, and control of medications and drugs. The practice of pharmacy requires excellent knowledge of drugs, their mechanism of action, side effects, interactions, mobility and toxicity. At the same time, it requires knowledge of treatment and understanding of the pathological process. Some specialties of pharmacists, such as that of clinical pharmacists, require other skills, e.g. knowledge about the acquisition and evaluation of physical and laboratory data.

The scope of pharmacy practice includes more traditional roles such as compounding and dispensing of medications, and it also includes more modern services related to health care, including clinical services, reviewing medications for safety and efficacy, and providing drug information. Pharmacists, therefore, are the experts on drug therapy and are the primary health professionals who optimize the use of medication for the benefit of the patients.

An establishment in which pharmacy is practiced is called a pharmacy or a chemist’s. In the United States and Canada, drugstores commonly sell medicines, as well as miscellaneous items such as confectionery, cosmetics, office supplies, toys, hair care products and magazines and occasionally refreshments and groceries.

In its investigation of herbal and chemical ingredients, the work of the apothecary may be regarded as a precursor of the modern sciences of chemistry and pharmacology, prior to the formulation of the scientific method.

Disciplines The field of pharmacy can generally be divided into three primary disciplines: Pharmaceutics Medicinal Chemistry and Pharmacognosy Pharmacy Practice The boundaries between these disciplines and with other sciences, such as biochemistry, are not always clear-cut.

Often, collaborative teams from various disciplines work together toward the introduction of new therapeutics and methods for patient care. However, pharmacy is not a basic or biomedical science in its typical form. Medicinal chemistry is also a distinct branch of synthetic chemistry combining pharmacology, organic chemistry, and chemical biology.

Pharmacology is sometimes considered as the 4th discipline of pharmacy. Although pharmacology is essential to the study of pharmacy, it is not specific to pharmacy. Both disciplines are distinct. Those who wish to practice both pharmacy and pharmacology receive separate training and degrees unique to either discipline.

Pharmacoinformatics is considered another new discipline, for systematic drug discovery and development with efficiency and safety.

Pharmacogenomics is the study of genetic-linked variants that effect patient clinical responses, allergies, and metabolism of drugs.

Professionals

The World Health Organization estimates that there are at least 2.6 million pharmacists and other pharmaceutical personnel worldwide.

Pharmacists Pharmacists are healthcare professionals with specialized education and training who perform various roles to ensure optimal health outcomes for their patients through the quality use of medicines. Pharmacists may also be small-business proprietors, owning the pharmacy in which they practice. Since pharmacists know about the mode of action of a particular drug, and its metabolism and physiological effects on the human body in great detail, they play an important role in optimization of drug treatment for an individual.

Pharmacists are represented internationally by the International Pharmaceutical Federation. They are represented at the national level by professional organisations such as the Royal Pharmaceutical Society in the UK, Pharmaceutical Society of Australia, Canadian Pharmacists Association, Indian Pharmacist Association, Pakistan Pharmacists Association, American Pharmacists Association, and the Malaysian Pharmaceutical Society.

In some cases, the representative body is also the registering body, which is responsible for the regulation and ethics of the profession.

In the United States, specializations in pharmacy practice recognized by the Board of Pharmacy Specialties include: cardiovascular, infectious disease, oncology, pharmacotherapy, nuclear, nutrition, and psychiatry. The Commission for Certification in Geriatric Pharmacy certifies pharmacists in geriatric pharmacy practice. The American Board of Applied Toxicology certifies pharmacists and other medical professionals in applied toxicology.

Pharmacy support staff Pharmacy technicians Pharmacy technicians support the work of pharmacists and other health professionals by performing a variety of pharmacy-related functions, including dispensing prescription drugs and other medical devices to patients and instructing on their use. They may also perform administrative duties in pharmaceutical practice, such as reviewing prescription requests with medic's offices and insurance companies to ensure correct medications are provided and payment is received.

Legislation requires the supervision of certain pharmacy technician's activities by a pharmacist. The majority of pharmacy technicians work in community pharmacies. In hospital pharmacies, pharmacy technicians may be managed by other senior pharmacy technicians. In the UK the role of a PhD in hospital pharmacy has grown and responsibility has been passed on to them to manage the pharmacy department and specialized areas in pharmacy practice allowing pharmacists the time to specialize in their expert field as medication consultants spending more time working with patients and in research. Pharmacy technicians are registered with the General Pharmaceutical Council. The GPhC is the regulator of pharmacists, pharmacy technicians, and pharmacy premises.

In the US, pharmacy technicians perform their duties under the supervision of pharmacists. Although they may perform, under supervision, most dispensing, compounding and other tasks, they are not generally allowed to perform the role of counseling patients on the proper use of their medications. Some states have a legally mandated pharmacist-topharmacy technician ratio.

Dispensing assistants

Dispensing assistants are commonly referred to as "dispensers" and in community pharmacies perform largely the same tasks as a pharmacy technician. They work under the supervision of pharmacists and are involved in preparing medicines for provision to patients.

Healthcare assistants/medicines counter assistants In the UK, this group of staff can sell certain medicines over the counter. They cannot prepare prescription-only medicines for supply to patients.

Education requirements There are different requirements of schooling according to the national jurisdiction where the student intends to practise.

United States In the United States, general pharmacist will attain a Doctor of Pharmacy Degree . The Pharm.D. can be completed in a minimum of six years, which includes two years of pre-pharmacy classes, and four years of professional studies. After graduating pharmacy school, it is highly suggested that the student go on to complete a one or two-year residency, which provides valuable experience for the student before going out independently to be a generalized or specialized pharmacist.

The curriculum specified for a Pharm.D. consists of at least 208-credit hours. Of the 208-credit hours, 68 are transferredcredit hours, and the remaining 140-credit hours are completed in the professional school. There are a series of required standardized tests that students have to pass throughout the process of pharmacy school. The standardized test to get into pharmacy school in the United States is called the Pharmacy College Admission Test. In a student's third professional year in pharmacy school, it is required to pass the Pharmacy Curriculum Outcomes Assessment. Once the Pharm.D. is attained after the fourth year professional school, the student is then eligible to take the North American Pharmacist Licensure Exam and the Multistate Pharmacy Jurisprudence Exam to work as a professional pharmacist.

History The earliest known compilation of medicinal substances was the Sushruta Samhita, an Indian Ayurveda treatise attributed to Sushruta in the 6th century BC. However, the earliest text as preserved dates to the 3rd or 4th century AD. Many Sumerian cuneiform clay tablets record prescriptions for medicine.

Ancient Egyptian pharmacological knowledge was recorded in various papyri such as the Ebers Papyrus of 1550 BC, and the Edwin Smith Papyrus of the 16th century BC. In Ancient Greece, Diocles of Carystus was one of several men studying the medicinal properties of plants. He wrote several treatises on the topic. The Greek physician Pedanius Dioscorides is famous for writing a five-volume book in his native Greek Περί ύλησ ιατρικήσ in the 1st century AD. The Latin translation De Materia Medica was used as a basis for many medieval texts and was built upon by many Middle Eastern scientists during the Islamic Golden Age, themselves deriving their knowledge from earlier Greek Byzantine medicine Byzantine Medicine.

Pharmacy in China dates at least to the earliest known Chinese manual, the Shennong Bencao Jing, dating back to the 1st century AD. It was compiled during the Han dynasty and was attributed to the mythical Shennong. Earlier literature included lists of prescriptions for specific ailments, exemplified by a manuscript "Recipes for 52 Ailments", found in the Mawangdui, sealed in 168 BC.

In Japan, at the end of the Asuka period and the early Nara period, the men who fulfilled roles similar to those of modern pharmacists were highly respected. The place of pharmacists in society was expressly defined in the Taihō Code and re-stated in the Yoro Code . Ranked positions in the pre-Heian Imperial court were established; and this organizational structure remained largely intact until the Meiji Restoration . In this highly stable hierarchy, the pharmacists—and even pharmacist assistants—were assigned status superior to all others in health-related fields such as physicians and acupuncturists. In the Imperial household, the pharmacist was even ranked above the two personal physicians of the Emperor.

There is a stone sign for a pharmacy with a tripod, a mortar, and a pestle opposite one for a doctor in the Arcadian Way in Ephesus near Kusadasi in Turkey. The current Ephesus dates back to 400 BC and was the site of the Temple of Artemis, one of the Seven Wonders of the World.

In Baghdad the first pharmacies, or drug stores, were established in 754, under the Abbasid Caliphate during the Islamic Golden Age. By the 9th century, these pharmacies were state-regulated.

The advances made in the Middle East in botany and chemistry led medicine in medieval Islam substantially to develop pharmacology. Muhammad ibn Zakarīya Rāzi, for instance, acted to promote the medical uses of chemical compounds.

Abu al-Qasim al-Zahrawi pioneered the preparation of medicines by sublimation and distillation. His Liber servitoris is of particular interest, as it provides the reader with recipes and explains how to prepare the 'simples' from which were compounded the complex drugs then generally used. Sabur Ibn Sahl, was, however, the first physician to initiate pharmacopoedia, describing a large variety of drugs and remedies for ailments. Al-Biruni wrote one of the most valuable Islamic works on pharmacology, entitled Kitab al-Saydalah, in which he detailed the properties of drugs and outlined the role of pharmacy and the functions and duties of the pharmacist. Avicenna, too, described no less than 700 preparations, their properties, modes of action, and their indications. He devoted in fact a whole volume to simple drugs in The Canon of Medicine. Of great impact were also the works by al-Maridini of Baghdad and Cairo, and Ibn al-Wafid, both of which were printed in Latin more than fifty times, appearing as De Medicinis universalibus et particularibus by 'Mesue' the younger, and the Medicamentis simplicibus by 'Abenguefit'. Peter of Abano translated and added a supplement to the work of al-Maridini under the title De Veneris. Al-Muwaffaq's contributions in the field are also pioneering. Living in the 10th century, he wrote The foundations of the true properties of Remedies, amongst others describing arsenious oxide, and being acquainted with silicic acid. He made clear distinction between sodium carbonate and potassium carbonate, and drew attention to the poisonous nature of copper compounds, especially copper vitriol, and also lead compounds. He also describes the distillation of sea-water for drinking.

In Europe, pharmacy-like shops began to appear during the 12th century. In 1240, Emperor Frederic II issued a decree by which the physician's and the apothecary's professions were separated.

There are pharmacies in Europe that have been in operation since medieval times. In Dubrovnik, a pharmacy that first opened in 1317 is located inside the Franciscan monastery: it is oldest operating pharmacy in Europe. In the Town Hall Square of Tallinn, there is a pharmacy dating from at least 1422. The medieval Esteve Pharmacy, located in Llívia, a Catalan enclave close to Puigcerdà, is a museum: the building dates back to the 15th century and the museum keeps albarellos from the 16th and 17th centuries, old prescription books and antique drugs.

Practice areas Pharmacists practice in a variety of areas including community pharmacies, hospitals, clinics, extended care facilities, psychiatric hospitals, and regulatory agencies. Pharmacists themselves may have expertise in a medical specialty.

Community pharmacy

A pharmacy is where most pharmacists practice the profession of pharmacy. It is the community pharmacy in which the dichotomy of the profession exists; health professionals who are also retailers.

Community pharmacies usually consist of a retail storefront with a dispensary, where medications are stored and dispensed. According to Sharif Kaf al-Ghazal, the opening of the first drugstores are recorded by Muslim pharmacists in Baghdad in 754 AD. In most countries, the dispensary is subject to pharmacy legislation; with requirements for storage conditions, compulsory texts, equipment, etc., specified in legislation. It was once the case that pharmacists stayed within the dispensary compounding/dispensing medications, but there has been an increasing trend towards the use of trained pharmacy technicians, with the pharmacist spending more time communicating with patients. Pharmacy technicians are now more dependent upon automation to assist them in their new role dealing with patients' prescriptions and patient safety issues.

Pharmacies are typically required to have a pharmacist on-duty at all times when they are open. It is also often a requirement for the owner of a pharmacy to be a registered pharmacist, but that is not the case in all jurisdictions, such that many retailers now include a pharmacy as a department of their store.

Likewise, many pharmacies are now rather grocery store-like in their design. In addition to medicines and prescriptions, many now sell a diverse arrangement of additional items such as cosmetics, shampoo, office supplies, confections, snack foods, durable medical equipment, greeting cards, and provide photo processing services.

Community pharmacies offer a unique added value by building direct relationships with their customers. They are able to provide more personalized, dedicated care to local members of their community and even offer enhanced services such as Medication Therapy Management, Medication Synchronization, and compounding. With the aid of pharmacy management systems and different integrated technologies, these smaller pharmacies are able to keep up with their large-scale competition.

In community pharmacy, prescriptions, medical devices and other over the counter products are dispensed by community pharmacists. Community pharmacists may be confronted with numerous ethical problems in their daily work. Ethical issues may exist while dispensing medications based on prescription and over the counter products.

Community pharmacists’ understanding of ethics, confidentiality, patient autonomy, trustworthiness and reliability may be the dynamics that affect community pharmacists’ values which may influence their decision making during ethical dilemmas. Most of the pharmacists face the ethical dilemma situations may be at least once a week in their pharmacies.

Community pharmacists may compromise on their values and ethical issues may not only because of patient's or physician's request but may also because of their employers' intrusion. Individual factors such as age, gender, work experience, and educational level and organizational factors such as the number of pharmacists in a pharmacy and location of pharmacy may influence the ethical dilemma of community pharmacists.

Hospital pharmacy Pharmacies within hospitals differ considerably from community pharmacies. Some pharmacists in hospital pharmacies may have more complex clinical medication management issues, and pharmacists in community pharmacies often have more complex business and customer relations issues.

Because of the complexity of medications including specific indications, effectiveness of treatment regimens, safety of medications and patient compliance issues, many pharmacists practicing in hospitals gain more education and training after pharmacy school through a pharmacy practice residency and sometimes followed by another residency in a specific

area. Those pharmacists are often referred to as clinical pharmacists and they often specialize in various disciplines of pharmacy.

For example, there are pharmacists who specialize in hematology/oncology, HIV/AIDS, infectious disease, critical care, emergency medicine, toxicology, nuclear pharmacy, pain management, psychiatry, anti-coagulation clinics, herbal medicine, neurology/epilepsy management, pediatrics, neonatal pharmacists and more.

Hospital pharmacies can often be found within the premises of the hospital. Hospital pharmacies usually stock a larger range of medications, including more specialized medications, than would be feasible in the community setting. Most hospital medications are unit-dose, or a single dose of medicine. Hospital pharmacists and trained pharmacy technicians compound sterile products for patients including total parenteral nutrition, and other medications are given intravenously. That is a complex process that requires adequate training of personnel, quality assurance of products, and adequate facilities.

Several hospital pharmacies have decided to outsource high-risk preparations and some other compounding functions to companies who specialize in compounding. The high cost of medications and drug-related technology and the potential impact of medications and pharmacy services on patient-care outcomes and patient safety require hospital pharmacies to perform at the highest level possible.

Clinical pharmacy Pharmacists provide direct patient care services that optimize the use of medication and promote health, wellness, and disease prevention. Clinical pharmacists care for patients in all health care settings, but the clinical pharmacy movement initially began inside hospitals and clinics. Clinical pharmacists often collaborate with physicians and other healthcare professionals to improve pharmaceutical care. Clinical pharmacists are now an integral part of the interdisciplinary approach to patient care. They often participate in patient care rounds for drug product selection.

The clinical pharmacist's role involves creating a comprehensive drug therapy plan for patient-specific problems, identifying goals of therapy, and reviewing all prescribed medications prior to dispensing and administration to the patient. The review process often involves an evaluation of the appropriateness of drug therapy and its efficacy. The pharmacist must also monitor for potential drug interactions, adverse drug reactions, and assess patient drug allergies while they design and initiate a drug therapy plan.

Ambulatory care pharmacy Since the emergence of modern clinical pharmacy, ambulatory care pharmacy practice has emerged as a unique pharmacy practice setting. Ambulatory care pharmacy is based primarily on pharmacotherapy services that a pharmacist provides in a clinic. Pharmacists in this setting often do not dispense drugs, but rather see patients in-office visits to manage chronic disease states.

In the U.S. federal health care system ambulatory care pharmacists are given full independent prescribing authority. In some states such North Carolina and New Mexico these pharmacist clinicians are given collaborative prescriptive and diagnostic authority. In 2011 the board of Pharmaceutical Specialties approved ambulatory care pharmacy practice as a separate board certification. The official designation for pharmacists who pass the ambulatory care pharmacy specialty certification exam will be Board Certified Ambulatory Care Pharmacist and these pharmacists will carry the initials BCACP. Compounding pharmacy/industrial pharmacy

Compounding involves preparing drugs in forms that are different from the generic prescription standard. This may include altering the strength, ingredients, or dosage form. Compounding is a way to create custom drugs for patients who may not be able to take the medication in its standard form, such as due to an allergy or difficulty swallowing.

Compounding is necessary for these patients to still be able to properly get the prescriptions they need.

One area of compounding is preparing drugs in new dosage forms. For example, if a drug manufacturer only provides a drug as a tablet, a compounding pharmacist might make a medicated lollipop that contains the drug. Patients who have difficulty swallowing the tablet may prefer to suck the medicated lollipop instead.

Another form of compounding is by mixing different strengths of capsules or tablets to yield the desired amount of medication indicated by the physician, physician assistant, nurse practitioner, or clinical pharmacist practitioner. This form of compounding is found at community or hospital pharmacies or in-home administration therapy.

Compounding pharmacies specialize in compounding, although many also dispense the same non-compounded drugs that patients can obtain from community pharmacies.

Consultant pharmacy Consultant pharmacy practice focuses more on medication regimen review than on actual dispensing of drugs.

Consultant pharmacists most typically work in nursing homes, but are increasingly branching into other institutions and non-institutional settings. Traditionally consultant pharmacists were usually independent business owners, though in the United States many now work for a large pharmacy management company such as Omnicare, Kindred Healthcare or Pharm Erica. This trend may be gradually reversing as consultant pharmacists begin to work directly with patients, primarily because many elderly people are now taking numerous medications but continue to live outside of institutional settings. Some community pharmacies employ consultant pharmacists and/or provide consulting services.

The main principle of consultant pharmacy is developed by Hepler and Strand in 1990.

Internet pharmacy Since about the year 2000, a growing number of Internet pharmacies have been established worldwide. Many of these pharmacies are similar to community pharmacies, and in fact, many of them are actually operated by brick-and-mortar community pharmacies that serve consumers online and those that walk in their door. The primary difference is the method by which the medications are requested and received. Some customers consider this to be more convenient and private method rather than traveling to a community drugstore where another customer might overhear about the drugs that they take. Internet pharmacies are also recommended to some patients by their physicians if they are homebound.

While most Internet pharmacies sell prescription drugs and require a valid prescription, some Internet pharmacies sell prescription drugs without requiring a prescription. Some customers order drugs from such pharmacies to avoid the "inconvenience" of visiting a doctor, or to obtain medications which their doctors were unwilling to prescribe. However, this practice has been criticized as potentially dangerous, especially by those who feel that only doctors can reliably assess contraindications, risk/benefit ratios, and an individual's overall suitability for use of medication. There also have been reports of such pharmacies dispensing substandard products.

Of particular concern with Internet pharmacies is the ease with which people, youth in particular, can obtain controlled substances via the Internet without a prescription issued by a doctor/practitioner who has an established doctorpatient relationship. There are instances where a practitioner issues a prescription, brokered by an Internet server, for a controlled substance to a "patient" s/he has never met. In the United States, in order for a prescription for a controlled substance to be valid, it must be issued for a legitimate medical purpose by a licensed practitioner acting in the course of

legitimate doctor-patient relationship. The filling pharmacy has a corresponding responsibility to ensure that the prescription is valid. Often, individual state laws outline what defines a valid patient-doctor relationship. The Food and Drug Administration is also heavily involved in monitoring internet pharmacies and has issued warnings against several companies who have violated the U.S. Federal Food, Drug, and Cosmetic Act that protects individuals against rogue online pharmacies.

Canada is home to dozens of licensed Internet pharmacies, many of which sell their lower-cost prescription drugs to U.S. consumers. In recent years, many consumers in the US, have turned to licensed Internet pharmacies in India, Israel, and the UK, which often have even lower prices than in Canada.

In the United States, there has been a push to legalize the importation of medications from Canada and other countries, in order to reduce consumer costs. While in most cases importation of prescription medications violates Food and Drug Administration regulations and federal laws, enforcement is generally targeted at international drug suppliers, rather than consumers. There is no known case of any U.S. citizens buying Canadian drugs for personal use with a prescription, which has ever been charged by authorities.

Veterinary pharmacy Veterinary pharmacies, sometimes called animal pharmacies, may fall in the category of hospital pharmacy, retail pharmacy or mail-order pharmacy. Veterinary pharmacies stock different varieties and different strengths of medications to fulfill the pharmaceutical needs of animals. Because the needs of animals, as well as the regulations on veterinary medicine, are often very different from those related to people, in some jurisdictions veterinary pharmacy may be kept separate from regular pharmacies.

Nuclear pharmacy Nuclear pharmacy focuses on preparing radioactive materials for diagnostic tests and for treating certain diseases.

Nuclear pharmacists undergo additional training specific to handling radioactive materials, and unlike in community and hospital pharmacies, nuclear pharmacists typically do not interact directly with patients.

Military pharmacy Military pharmacy is a different working environment to civilian practise due to the fact that military pharmacy technicians perform duties such as evaluating medication orders, preparing medication orders, and dispensing medications. This would be illegal in civilian pharmacies because these duties are required to be performed by a licensed registered pharmacist. In the US military, state laws that prevent technicians from counseling patients or doing the final medication check prior to dispensing to patients do not apply.

Pharmacy informatics Pharmacy informatics is the combination of pharmacy practice science and applied information science. Pharmacy informaticists work in many practice areas of pharmacy, however, they may also work in information technology departments or for healthcare information technology vendor companies. As a practice area and specialist domain, pharmacy informatics is growing quickly to meet the needs of major national and international patient information projects and health system interoperability goals. Pharmacists in this area are trained to participate in medication management system development, deployment, and optimization.

Specialty pharmacy

Specialty pharmacies supply high-cost injectable, oral, infused, or inhaled medications that are used for chronic and complex disease states such as cancer, hepatitis, and rheumatoid arthritis. Unlike a traditional community pharmacy where prescriptions for any common medication can be brought in and filled, specialty pharmacies carry novel medications that need to be properly stored, administered, carefully monitored, and clinically managed. In addition to supplying these drugs, specialty pharmacies also provide lab monitoring, adherence counseling, and assist patients with cost-containment strategies needed to obtain their expensive specialty drugs. In the US, it is currently the fastestgrowing sector of the pharmaceutical industry with 19 of 28 newly FDA approved medications in 2013 being specialty drugs.

Due to the demand for clinicians who can properly manage these specific patient populations, the Specialty Pharmacy Certification Board has developed a new certification exam to certify specialty pharmacists. Along with the 100 questions computerized multiple-choice exam, pharmacists must also complete 3,000 hours of specialty pharmacy practice within the past three years as well as 30 hours of specialty pharmacist continuing education within the past two years.

Pharmaceutical sciences The pharmaceutical sciences are a group of interdisciplinary areas of study concerned with the design, action, delivery, and disposition of drugs. They apply knowledge from chemistry, biology, epidemiology, statistics, chemo metrics, mathematics, physics, and chemical engineering.

The pharmaceutical sciences are further subdivided into several specific specialties, with four main branches: Pharmacology: the study of the biochemical and physiological effects of drugs on human beings.

Pharmacodynamics: the study of the cellular and molecular interactions of drugs with their receptors. Simply "What the drug does to the body" Pharmacokinetics: the study of the factors that control the concentration of drug at various sites in the body. Simply "What the body does to the drug" Pharmaceutical toxicology: the study of the harmful or toxic effects of drugs.

Pharmacogenomics: the study of the inheritance of characteristic patterns of interaction between drugs and organisms.

Pharmaceutical chemistry: the study of drug design to optimize pharmacokinetics and pharmacodynamics, and synthesis of new drug molecules.

Pharmaceutics: the study and design of drug formulation for optimum delivery, stability, pharmacokinetics, and patient acceptance.

Pharmacognosy: the study of medicines derived from natural sources.

As new discoveries advance and extend the pharmaceutical sciences, subspecialties continue to be added to this list.

Importantly, as knowledge advances, boundaries between these specialty areas of pharmaceutical sciences are beginning to blur. Many fundamental concepts are common to all pharmaceutical sciences. These shared fundamental concepts further the understanding of their applicability to all aspects of pharmaceutical research and drug therapy.

Pharmacocybernetics is an emerging field that describes the science of supporting drugs and medications use through the application and evaluation of informatics and internet technologies, so as to improve the pharmaceutical care of patients.

Society and culture Etymology The word pharmacy is derived from Old French farmacie "substance, such as a food or in the form of a medicine which has a laxative effect" from Medieval Latin pharmacia from Greek pharmakeia "a medicine", which itself derives from pharm Akon, meaning "drug, poison, spell" .

Separation of prescribing and dispensing Separation of prescribing and dispensing, also called dispensing separation, is a practice in medicine and pharmacy in which the physician who provides a medical prescription is independent from the pharmacist who provides the prescription drug.

In the Western world there are centuries of tradition for separating pharmacists from physicians. In Asian countries, it is traditional for physicians to also provide drugs.

In contemporary time researchers and health policy analysts have more deeply considered these traditions and their effects. Advocates for separation and advocates for combining make similar claims for each of their conflicting perspectives, saying that separating or combining reduces conflict of interest in the healthcare industry, unnecessary health care, and lowers costs, while the opposite causes those things. Research in various places reports mixed outcomes in different circumstances.

The future of pharmacy In the coming decades, pharmacists are expected to become more integral within the health care system. Rather than simply dispensing medication, pharmacists are increasingly expected to be compensated for their patient care skills. In particular, Medication Therapy Management includes the clinical services that pharmacists can provide for their patients. Such services include a thorough analysis of all medication currently being taken by an individual. The result is a reconciliation of medication and patient education resulting in increased patient health outcomes and decreased costs to the health care system.

This shift has already commenced in some countries; for instance, pharmacists in Australia receive remuneration from the Australian Government for conducting comprehensive Home Medicines Reviews. In Canada, pharmacists in certain provinces have limited prescribing rights or are remunerated by their provincial government for expanded services such as medications reviews. In the United Kingdom, pharmacists who undertake additional training are obtaining prescribing rights and this is because of pharmacy education. They are also being paid for by the government for medicine use reviews. In Scotland, the pharmacist can write prescriptions for Scottish registered patients of their regular medications, for the majority of drugs, except for controlled drugs, when the patient is unable to see their doctor, as could happen if they are away from home or the doctor is unavailable. In the United States, pharmaceutical care or clinical pharmacy has had an evolving influence on the practice of pharmacy. Moreover, the Doctor of Pharmacy degree is now required before entering practice and some pharmacists now complete one or two years of residency or fellowship training following graduation. In addition, consultant pharmacists, who traditionally operated primarily in nursing homes are now expanding into direct consultation with patients, under the banner of "senior care pharmacy".

In addition to patient care, pharmacies will be a focal point for medical adherence initiatives. There is enough evidence to show that integrated pharmacy based initiatives significantly impact adherence for chronic patients. For example, a study published in NIH shows "pharmacy based interventions improved patients' medication adherence rates by 2.1 percent and increased physicians' initiation rates by 38 percent, compared to the control group".

Pharmacy journals List of Pharmacy Journals Symbols The symbols most commonly associated with pharmacy are the mortar and pestle and the ℞ character, which is often written as "Rx" in typed text; the green Greek cross in France, Argentina, the United Kingdom, Belgium, Ireland, Italy, Spain, and India; the Bowl of Hygeia often used in the Netherlands but may be seen combined with other symbols elsewhere. Other common symbols include conical measures, and caduceuses, in their logos. A red stylized letter A in used Germany and Austria. The show globe was used in the US until the early 20th century;the Gaper in the Netherlands is increasingly rare.

See also Notes and references Notes References References Asai, T. . Nyokan Tūkai. Tokyo: Kōdan-Sha. Titsingh, Isaac, Ed. ., Nipon o daï itsi ran; ou, Annales des empereurs du Japon. Paris: Oriental Translation Fund of Great Britain and Ireland.

– A landmark study in hospital pharmacy performance based on an extensive literature review and the collective experience of the Health Systems Pharmacy Executive Alliance.

External links Collection of internet resources related to the history of pharmacy – Information about the history of the American Drugstore Library of botanical, medical, pharmaceutical, and scientific books and periodicals, and works of allied sciences American Institute of the History of Pharmacy—resources in the history of pharmacy Federation representing national associations of pharmacists and pharmaceutical scientists. Information and resources relating to pharmacy education, practice, science and policy German association of pharmacy students Vietnam association of pharmacy OTC.

RadiographyRadiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography and industrial radiography.

Similar techniques are used in airport security. To create an image in conventional radiography, a beam of X-rays is produced by an X-ray generator and is projected toward the object. A certain amount of the X-rays or other radiation is absorbed by the object, dependent on the object's density and structural composition. The X-rays that pass through the object are captured behind the object by a detector. The generation of flat two dimensional images by this technique is called projectional radiography. In computed tomography an X-ray source and its associated detectors rotate around the subject which itself moves through the conical X-ray beam produced. Any given point within the subject is crossed from many directions by many different beams at different times. Information regarding attenuation of these beams is collated and subjected to computation to generate two dimensional images in three planes which can be further processed to produce a three dimensional image.

Medical uses Since the body is made up of various substances with differing densities, Ionising and non-ionizing radiation can be used to reveal the internal structure of the body on an image receptor by highlighting these differences using attenuation, or in the case of ionising radiation, the absorption of X-ray photons by the denser substances . The discipline involving the study of anatomy through the use of radiographic images is known as radiographic anatomy. Medical radiography acquisition is generally carried out by radiographers, while image analysis is generally done by radiologists. Some radiographers also specialise in image interpretation. Medical radiography includes a range of modalities producing many different types of image, each of which has a different clinical application.

Projectional radiography The creation of images by exposing an object to X-rays or other high-energy forms of electromagnetic radiation and capturing the resulting remnant beam as a latent image is known as "projection radiography." The "shadow" may be converted to light using a fluorescent screen, which is then captured on photographic film, it may be captured by a phosphor screen to be "read" later by a laser, or it may directly activate a matrix of solid-state detectors . Bone and some organs especially lend themselves to projection radiography. It is a relatively low-cost investigation with a high diagnostic yield. The difference between soft and hard body parts stems mostly from the fact that carbon has a very low X-ray cross section compared to calcium.

Computed tomography Computed tomography or CT scan uses ionizing radiation in conjunction with a computer to create images of both soft and hard tissues. These images look as though the patient was sliced like bread. Though CT uses a higher amount of ionizing x-radiation than diagnostic x-rays, with advances in technology, levels of CT radiation dose and scan times have reduced. CT exams are generally short, most lasting only as long as a breath-hold, Contrast agents are also often used, depending on the tissues needing to be seen. Radiographers perform these examinations, sometimes in conjunction with a radiologist.

Dual energy X-ray absorptiometry DEXA, or bone densitometry, is used primarily for osteoporosis tests. It is not projection radiography, as the X-rays are emitted in 2 narrow beams that are scanned across the patient, 90 degrees from each other. Usually the hip, lower back, or heel are imaged, and the bone density is determined and given a number. It is not used for bone imaging, as the image quality is not good enough to make an accurate diagnostic image for fractures, inflammation, etc. It can also be

used to measure total body fat, though this is not common. The radiation dose received from DEXA scans is very low, much lower than projection radiography examinations.

Fluoroscopy Fluoroscopy is a term invented by Thomas Edison during his early X-ray studies. The name refers to the fluorescence he saw while looking at a glowing plate bombarded with X-rays.

The technique provides moving projection radiographs. Fluoroscopy is mainly performed to view movement, or to guide a medical intervention, such as angioplasty, pacemaker insertion, or joint repair/replacement. The latter can often be carried out in the operating theatre, using a portable fluoroscopy machine called a C-arm. It can move around the surgery table and make digital images for the surgeon. Biplanar Fluoroscopy works the same as single plane fluoroscopy except displaying two planes at the same time. The ability to work in two planes is important for orthopedic and spinal surgery and can reduce operating times by eliminating re-positioning.

Angiography Angiography is the use of fluoroscopy to view the cardiovascular system. An iodine-based contrast is injected into the bloodstream and watched as it travels around. Since liquid blood and the vessels are not very dense, a contrast with high density is used to view the vessels under X-ray. Angiography is used to find aneurysms, leaks, blockages, new vessel growth, and placement of catheters and stents. Balloon angioplasty is often done with angiography.

Contrast radiography Contrast radiography uses a radiocontrast agent, a type of contrast medium, to make the structures of interest stand out visually from their background. Contrast agents are required in conventional angiography, and can be used in both projectional radiography and computed tomography .

Other medical imaging Although not technically radiographic techniques due to not using X-rays, imaging modalities such as PET and MRI are sometimes grouped in radiography because the radiology department of hospitals handle all forms of imaging.

Treatment using radiation is known as radiotherapy.

Industrial radiography Industrial radiography is a method of non-destructive testing where many types of manufactured components can be examined to verify the internal structure and integrity of the specimen. Industrial Radiography can be performed utilizing either X-rays or gamma rays. Both are forms of electromagnetic radiation. The difference between various forms of electromagnetic energy is related to the wavelength. X and gamma rays have the shortest wavelength and this property leads to the ability to penetrate, travel through, and exit various materials such as carbon steel and other metals. Specific methods include industrial computed tomography.

Image quality Image quality will depend on resolution and density.

Resolution is the ability an image to show closely spaced structure in the object as separate entities in the image while density is the blackening power of the image.

Sharpness of a radiographic image is strongly determined by the size of the X-ray source. This is determined by the area of the electron beam hitting the anode.

A large photon source results in more blurring in the final image and is worsened by an increase in image formation distance. This blurring can be measured as a contribution to the modulation transfer function of the imaging system.

Radiation dose The dosage of radiation applied in radiography varies by procedure. For example, the effective dosage of a chest x-ray is 0.1 mSv, while an abdominal CT is 10 mSv. The American Association of Physicists in Medicine have stated that the "risks of medical imaging at patient doses below 50 mSv for single procedures or 100 mSv for multiple procedures over short time periods are too low to be detectable and may be nonexistent." Other scientific bodies sharing this conclusion include the International Organization of Medical Physicists, the UN Scientific Committee on the Effects of Atomic Radiation, and the International Commission on Radiological Protection. Nonetheless, radiological organizations, including the Radiological Society of North America and the American College of Radiology, as well as multiple government agencies, indicate safety standards to ensure that radiation dosage is as low as possible.

Shielding Lead is the most common shield against X-rays because of its high density, stopping power, ease of installation and low cost. The maximum range of a high-energy photon such as an X-ray in matter is infinite; at every point in the matter traversed by the photon, there is a probability of interaction. Thus there is a very small probability of no interaction over very large distances. The shielding of photon beam is therefore exponential; doubling the thickness of shielding will square the shielding effect.

The following table shows the recommended thickness of lead shielding in function of X-ray energy, from the Recommendations by the Second International Congress of Radiology.

Campaigns In response to increased concern by the public over radiation doses and the ongoing progress of best practices, The Alliance for Radiation Safety in Pediatric Imaging was formed within the Society for Pediatric Radiology. In concert with the American Society of Radiologic Technologists, the American College of Radiology, and the American Association of Physicists in Medicine, the Society for Pediatric Radiology developed and launched the Image Gently campaign which is designed to maintain high quality imaging studies while using the lowest doses and best radiation safety practices available on pediatric patients. This initiative has been endorsed and applied by a growing list of various professional medical organizations around the world and has received support and assistance from companies that manufacture equipment used in radiology.

Following upon the success of the Image Gently campaign, the American College of Radiology, the Radiological Society of North America, the American Association of Physicists in Medicine, and the American Society of Radiologic Technologists have launched a similar campaign to address this issue in the adult population called Image Wisely. The World Health Organization and International Atomic Energy Agency of the United Nations have also been working in this area and have ongoing projects designed to broaden best practices and lower patient radiation dose.

Provider payment Contrary to advice that emphasises only conducting radiographs when in the patient's interest, recent evidence suggests that they are used more frequently when dentists are paid under fee-for-service Equipment Sources

In medicine and dentistry, projectional radiography and computed tomography images generally use X-rays created by X-ray generators, which generate X-rays from X-ray tubes. The resultant images from the radiograph or CT scanner are correctly referred to as "radiograms"/"roentgenograms" and "tomograms" respectively.

A number of other sources of X-ray photons are possible, and may be used in industrial radiography or research; these include betatrons, and linear accelerators and synchrotrons. For gamma rays, radioactive sources such as 192Ir, 60Co or 137Cs are used.

Grid A Bucky-Potter grid may be placed between the patient and the detector to reduce the quantity of scattered x-rays that reach the detector. This improves the contrast resolution of the image, but also increases radiation exposure for the patient.

Detectors Detectors can be divided into two major categories: imaging detectors, now mostly replaced by various digitizing devices like image plates or flat panel detectors) and dose measurement devices .

Side markers A radiopaque anatomical side marker is added to each image. For example, if the patient has their right hand x-rayed, the radiographer includes a radiopaque "R" marker within the field of the x-ray beam as an indicator of which hand has been imaged. If a physical marker is not included, the radiographer may add the correct side marker later as part of digital post-processing.

Image intensifiers and array detectors As an alternative to X-ray detectors, image intensifiers are analog devices that readily convert the acquired X-ray image into one visible on a video screen. This device is made of a vacuum tube with a wide input surface coated on the inside with cesium iodide. When hit by X-rays material phosphors which causes the photocathode adjacent to it to emit electrons? These electrons are then focus using electron lenses inside the intensifier to an output screen coated with phosphorescent materials. The image from the output can then be recorded via a camera and displayed.

Digital devices known as array detectors are becoming more common in fluoroscopy. These devices are made of discrete pixelated detectors known as thin-film transistors which can either work indirectly by using photo detectors that detect light emitted from a scintillator material such as CsI, or directly by capturing the electrons produced when the X-rays hit the detector. Direct detector do not tend to experience the blurring or spreading effect caused by phosphorescent scintillators of or film screens since the detectors are activated directly by X-ray photons.

Dual-energy Dual-energy radiography is where images are acquired using two separate tube voltages. This is the standard method for bone densitometry. It is also used in CT pulmonary angiography to decrease the required dose of iodinated contrast.

History Radiography's origins and fluoroscopy's origins can both be traced to 8 November 1895, when German physics professor Wilhelm Conrad Rontgen discovered the X-ray and noted that, while it could pass through human tissue, it could not pass through bone or metal. Röntgen referred to the radiation as "X", to indicate that it was an unknown type of radiation. He received the first Nobel Prize in Physics for his discovery.

There are conflicting accounts of his discovery because Röntgen had his lab notes burned after his death, but this is a likely reconstruction by his biographers: Röntgen was investigating cathode rays using a fluorescent screen painted with barium platinocyanide and a Crookes tube which he had wrapped in black cardboard to shield its fluorescent glow. He noticed a faint green glow from the screen, about 1 metre away. Röntgen realized some invisible rays coming from the tube were passing through the cardboard to make the screen glow: they were passing through an opaque object to affect the film behind it.

Röntgen discovered X-rays' medical use when he made a picture of his wife's hand on a photographic plate formed due to X-rays. The photograph of his wife's hand was the first ever photograph of a human body part using X-rays. When she saw the picture, she said, "I have seen my death."

The United States saw its first medical X-ray obtained using a discharge tube of Ivan Pulyui's design. In January 1896, on reading of Rontgen’s discovery, Frank Austin of Dartmouth College tested all of the discharge tubes in the physics laboratory and found that only the Pulyui tube produced X-rays. This was a result of Pulyui's inclusion of an oblique "target" of mica, used for holding samples of fluorescent material, within the tube. On 3 February 1896 Gilman Frost, professor of medicine at the college, and his brother Edwin Frost, professor of physics, exposed the wrist of Eddie McCarthy, whom Gilman had treated some weeks earlier for a fracture, to the X-rays and collected the resulting image of the broken bone on gelatin photographic plates obtained from Howard Langill, a local photographer also interested in Röntgen's work.

X-rays were put to diagnostic use very early; for example, Alan Archibald Campbell-Swinton opened a radiographic laboratory in the United Kingdom in 1896, before the dangers of ionizing radiation were discovered. Indeed, Marie Curie pushed for radiography to be used to treat wounded soldiers in World War I. Initially, many kinds of staff conducted radiography in hospitals, including physicists, photographers, physicians, nurses, and engineers. The medical speciality of radiology grew up over many years around the new technology. When new diagnostic tests were developed, it was natural for the Radiographers to be trained in and to adopt this new technology. Radiographers now perform fluoroscopy, computed tomography, mammography, ultrasound, nuclear medicine and magnetic resonance imaging as well. Although a nonspecialist dictionary might define radiography quite narrowly as "taking X-ray images", this has long been only part of the work of "X-ray departments", radiographers, and radiologists. Initially, radiographs were known as roentgenograms, while Skiagrapher was used until about 1918 to mean Radiographer. The Japanese term for the radiograph, レントゲン, shares its etymology with the original English term.

See also Autoradiograph Background radiation Computer-aided diagnosis Imaging science List of civilian radiation accidents Medical imaging in pregnancy Radiation Radiation contamination Radiographer

Thermography References Further reading External links Medical Image Database , Karlsruhe University of Applied Sciences The radiology information resource for patients: Radiography.